A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

Rationale:

A. "Swaddle the newborn before securing the clips.": Swaddling before placing the newborn in the car seat is unsafe because it can prevent proper restraint and increase the risk of injury during a crash. The newborn should be secured directly by the harness straps.

B. "Add a soft head support in the car seat if necessary.": Adding aftermarket soft head supports can interfere with the car seat’s harness system and safety performance. Only manufacturer-approved accessories should be used.

C. "Secure the straps across the newborn's chest at the level of their armpits.": The harness straps should be positioned at or just below the newborn’s shoulders, with the chest clip placed at the armpit level to ensure optimal restraint and prevent movement during sudden stops.

D. "Ensure that the car seat is positioned at a 90 degree incline.": The car seat should be reclined at approximately a 45-degree angle to prevent the newborn’s head from falling forward and obstructing the airway during travel.

Rationale:

A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.

B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.

C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.

E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.