Answer to Question 1
3
Rationale:
1. Although knowing how to bathe a newborn is important, adequate hydration is a higher priority.
2. Child-proofing the home is not necessary until the baby begins to crawl. This is a low priority at this time.
3. Wet diapers are an indication of hydration of the newborn. This is the highest priority.
4. Preventing flat spots on the back or side of the head is primarily a cosmetic issue. Hydration is a higher priority.
Answer to Question 2
3
Rationale:
1. Paternity testing is a lower priority than the physiologic well-being of the client and fetus.
2. A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
3. Pre-eclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority.
4. During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor.
NUrse :0
The nurse is using Standard Precautions to draw blood.
The nurse applies a pulse oximeter sensor on the client’s finger.
Patient teaching: nose and sinus assessment
Performing the Trendelenburg’s test: Applying tourniquet
National Patient Safety Goals for Acute-Care Hospitals