A nurse is assisting in the care of a client

Which of the following interventions should the nurse plan to implement? Select all that apply.

A) "Carry your newborn back to the nursery in your arm when you need to rest.": This statement is not recommended. Carrying the newborn around, especially when the mother is feeling fatigued or unwell, can increase the risk of accidental drops or falls. Newborns should be placed in a bassinet or crib, and if the mother needs to rest, she should use assistance to ensure the baby is safely secured in their sleeping area.

B) "Request that the nurses show their nursing license prior to removing your newborn from the room.": While it’s important to ensure that the staff is authorized to care for the newborn, it may not be practical or necessary to request to see a nursing license every time someone comes to take the baby. Instead, the hospital usually has strict protocols in place for identifying staff, and it is better to rely on the facility's established security measures to verify authorized personnel.

C) "Leave your newborn in the bassinet in your room while you use the bathroom.": This statement is not ideal because, while it may seem safer to leave the baby in the bassinet, the nurse should encourage the mother to keep the baby nearby or alert a nurse to assist if needed. It is safer to have the baby in a secure place or ask for help to avoid the risk of falls or accidents while the mother is not attending to the baby.

D) "Alert the staff if any of your newborn's identification bands are missing.": This is the correct and most important instruction. Newborns should always be closely monitored to prevent abductions or mix-ups, and the identification bands are critical for verifying the baby's identity. If any identification bands are missing, it is essential to notify the staff immediately to ensure the newborn’s safety and prevent any potential security risks.

A) Measure the client’s vital signs: The first priority after a fall is to assess the client's physical condition to determine if any immediate harm or injury has occurred. Taking the vital signs allows the nurse to assess for signs of shock, internal injury, or other complications that could require urgent intervention. This step should be done before notifying the provider or completing paperwork.

B) Notify the client's provider: While notifying the provider is important, it is not the first step. The nurse's priority is to assess the client’s condition and ensure they are stable. Once the client’s condition has been assessed, the provider can be notified if necessary.

C) Complete an incident report: An incident report should be completed after the client’s immediate needs are addressed. While documentation of the fall is important, the priority is the client’s safety and well-being. The nurse should first evaluate and stabilize the client before focusing on administrative tasks like the incident report.

D) Document the fall in the client's medical record: Although documentation is essential, the first priority should always be assessing and stabilizing the client. Once the client’s safety is ensured, then documenting the event and any findings is appropriate.