A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.

B. Review cast care instructions with the child's parents: While parent education is important, it is secondary to immediate interventions that address pain, swelling, and preparation for the procedure. Priority actions focus first on the child’s current needs and safety.

C. Elevate the affected forearm with pillows: Elevation helps reduce edema and pain in the fractured extremity and prevents further swelling. This is a critical nursing intervention for acute fracture management before and after casting.

D. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.

E. Place a nonadherent dressing on the right knee abrasion: Caring for minor abrasions is important but is not a priority compared with interventions addressing fracture management, pain, and preparation for cast application.

F. Administer Ibuprofen 200 mg PO: Pain management is a priority in fracture care to maintain comfort and reduce distress. Administering analgesics before cast application helps the child tolerate the procedure and facilitates cooperation.

Rationale:

A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.

B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.

C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.

D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.