A client at 39 weeks gestation is admitted in early labor. During the focused assessment, the practical nurse (PN) reviews the obstetrical history of the client who states that she has been pregnant five times but has only two living children, both of whom were full-term. The other three pregnancies were miscarriages during the first trimester. Which parity should the PN document for the term, premature, abortion, and living children (TPAL) for this client?

Taking a rectal temperature requires a higher level of skill and carries a higher risk of injury compared to other methods, especially when dealing with a 2-year-old child with leukemia. Given the client's condition, it is important to minimize any potential harm or discomfort. Taking a tympanic temperature is a safer alternative that provides an accurate reading without the risk of injury.
B. Reminding the UAP to lubricate the thermometer before insertion is not appropriate because the PN should not encourage or support the UAP in performing a rectal temperature on a high-risk client. The focus should be on using a safer and less invasive method.
C. Instructing the UAP to report the results to the PN immediately is not necessary in this situation because the PN has already determined that taking a rectal temperature is not appropriate.
Instead, the PN should guide the UAP toward using the tympanic method.

D. Observing the UAP to ensure the thermometer is inserted correctly is not appropriate in this case because the PN has already determined that taking a rectal temperature is not the recommended course of action. It is more appropriate to redirect the UAP to use an alternative method.

Choice A reason:

Administering the medication and alerting the charge nurse is not necessary in this scenario. The heart rate of 120 beats/minute is within the normal range for a 2-month-old infant, which is typically between 80 to 160 beats per minute. Therefore, there is no immediate concern that would require alerting the charge nurse.

Choice B reason:

Holding the medication and documenting the cardiac assessment would be appropriate if the heart rate were outside the normal range or if there were other signs of digoxin toxicity or adverse effects. Since the heart rate is within the normal range, this action is not warranted.

Choice C reason:

Administering the medication and documenting the heart rate is the correct action. The heart rate of 120 beats/minute falls within the normal range for a 2-month-old infant¹². Digoxin is prescribed to manage certain heart conditions, and as long as the heart rate is within the normal range and there are no signs of toxicity, the medication should be given as prescribed.

Choice D reason:

Holding the medication and rechecking the heart rate in 1 hour would be considered if the heart rate were borderline or if there were concerns about the stability of the infant's condition. Since the heart rate is stable and within the normal range, this action is unnecessary.