Author Question: A nurse documents care given to the client during a shift. The client experienced a reduction in ... (Read 64 times)

ENagel · **on:** Jul 22, 2018

A nurse documents care given to the client during a shift. The client experienced a reduction in pain level while ambulating, took a shower, visited with family, and ate a small dinner.

The nurse plans to include which information in the oral end-of-shift report? 1. The client's visit with family
2. The client's taking a shower
3. The last antibiotics given
4. The client's response to ambulation

Question 2

A new mother tells the nurse that her friend's baby died from sudden infant death syndrome, and she wants to make sure that her baby is safe. Which of the following should the nurse do to assist the mother?

1. Encourage the mother to place the child in a face-down position for sleep
2. Suggest the mother avoid immunizing the child
3. Instruct the mother to keep the baby with her at all times to assess for apnea periods
4. There is no one cause for the syndrome; the best thing is to keep the baby healthy.

Swizqar · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4. The client's response to ambulation

Rationale:
In order to provide for the client's safety, the nurse would pass on the client's response to ambulation so that the oncoming staff can take fall precautions. Visiting with the family need not be mentioned at change of shift but should be documented. Taking a shower does not need to be reported, only documented. Antibiotics are reflected on the medication administration record (MAR). The nurse would also report any as-needed medications given and when they were last given.

Answer to Question 2

4. There is no one cause for the syndrome; the best thing is to keep the baby healthy.

Rationale:
The best intervention would be for the nurse to explain that there is no single cause for the syndrome and for the mother to keep the baby healthy. According to one theory for the syndrome, a face-down position could encourage a reduction in respirations. The nurse should instruct the mother to position the baby face-up for sleep. Immunizations and newborn apnea have not been found to be associated with the syndrome.