A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?
A hospital volunteer leaves the unit with the newborn to allow caregiver to rest.
Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening
An assistive personnel weighs and bathes the newborn in an empty client room.
The caregiver and newborn have matching hospital identification bracelets
The Correct Answer is A
A. A hospital volunteer leaves the unit with the newborn to allow caregiver to rest: Hospital volunteers are not authorized to transport newborns, especially off the unit. Removing a newborn without proper clinical authorization represents a significant security risk and requires immediate initiation of a security alert to prevent potential abduction.
B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: A licensed nurse transporting a newborn for required screening is an expected and appropriate practice. This follows standard hospital protocol and does not indicate a security concern when proper identification procedures are followed.
C. An assistive personnel weighs and bathes the newborn in an empty client room: Assistive personnel may perform routine newborn care under facility policy and nursing delegation. While supervision and proper identification are required, this situation alone does not necessitate a security alert.
D. The caregiver and newborn have matching hospital identification bracelets: Matching identification bands indicate that correct newborn identification procedures are in place. This supports infant safety and does not represent a situation requiring security intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Negative varicella titer: A negative varicella titer indicates the client is susceptible to chickenpox. While vaccination is recommended postpartum, this finding does not require urgent intervention during pregnancy because live vaccines cannot be given while pregnant.
B. Rubella titer nonimmune: A nonimmune rubella titer identifies susceptibility to rubella. Vaccination is provided postpartum, not during pregnancy, so immediate follow-up during the current pregnancy is not required.
C. Positive Rh factor: A positive Rh factor indicates the client is Rh-positive, which poses no risk for hemolytic disease of the newborn. No immediate intervention is required; routine monitoring continues.
D. Positive serologic test for syphilis: A positive syphilis test requires prompt follow-up because untreated maternal syphilis can cause miscarriage, stillbirth, or congenital infection. Early treatment with antibiotics during pregnancy is critical to prevent complications for both mother and fetus.
Correct Answer is C
Explanation
A. Copy of the client's advance directives: Advance directives are part of the client’s legal and medical record but are not included in postmortem documentation. Postmortem charting focuses on care provided after death and body identification rather than prior treatment preferences.
B. Cause of the client's death: Determining and documenting the cause of death is the responsibility of the provider, not the nurse. The nurse may document the time death was pronounced and by whom, but listing the cause exceeds the nursing scope of documentation.
C. Location of the identification tag on the client's body: Proper identification is a critical component of postmortem care to ensure correct body handling and prevent errors. Documenting the placement of identification tags supports legal requirements and continuity of care through the morgue and funeral services.
D. Last set of the client's vital signs: Vital signs are not obtained or documented after death has occurred. Postmortem documentation focuses on confirmation of death, care of the body, and disposition rather than physiological measurements.
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