A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.

Choice B rationale:

Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.

Choice C rationale:

Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.

Choice D rationale:

Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.

Choice A rationale:

Placing the client's arms raised above her head with her legs elevated on pillows (choice A) is not the correct position for a lumbar puncture. This position does not facilitate proper alignment of the spine and may hinder the procedure.

Choice B rationale:

The Trendelenburg position with the body in Sims' position (choice B) is not the correct position for a lumbar puncture. This position is not commonly used for lumbar punctures and may not provide the necessary anatomical alignment for a successful procedure.

Choice C rationale:

Placing the client prone with her arms at her side and her legs extended (choice C) is not the appropriate position for a lumbar puncture. This position does not allow for proper access to the lumbar region and may impede the procedure.

Choice D rationale:

The correct position for a lumbar puncture is to have the client flex their head to the chest and pull their knees up to the abdomen (choice D) This position maximizes the space between the lumbar vertebrae, making it easier for the provider to access the subarachnoid space for cerebrospinal fluid collection.