A nurse is assisting with the care of a newborn.

For each potential nursing intervention, click to specify if the action appropriate, nonessential, or contraindicated for the newborn.

A. Tell the children to alternate standing on one foot and observe their balance: Assessing balance does not evaluate spinal curvature or detect scoliosis. While balance testing may identify neuromuscular issues, it is not part of standard scoliosis screening and does not reveal lateral spinal deviations.

B. Ask the children to bend forward at the waist and observe them from behind: The forward bend (Adam’s forward bend) test is the recommended screening method for scoliosis. Observing from behind allows the nurse to detect asymmetry in the shoulders, ribs, or hips, which may indicate spinal curvature. This method is simple, noninvasive, and effective for early detection.

C. Tell the children to stand up straight and observe them facing forward: Viewing the child from the front while standing upright may reveal gross asymmetry but is less sensitive than the forward bend test. Subtle spinal curvatures are often not noticeable when the child is standing upright.

D. Ask the children to raise their hands over their head and turn from side to side: Raising arms and twisting does not provide clear visualization of spinal asymmetry. Scoliosis screening relies on observing the alignment of the spine and rib cage during forward flexion, not rotational movements.

A. Indication: The prescription clearly states that acetaminophen is to be administered for a temperature above 38.5°C (101.3°F), which provides an appropriate therapeutic indication. Fever reduction is a standard and evidence-based use of acetaminophen in infants. The indication is specific and does not require clarification.

B. Frequency: The order includes the medication name, dose, route, and indication but does not specify how often the medication can be administered. Acetaminophen requires clear dosing intervals, typically every 4 to 6 hours, with a maximum daily dose to prevent hepatotoxicity. Without a defined frequency, there is a risk of overdose or inappropriate administration timing.

C. Route: The prescription specifies oral administration (PO), which is an appropriate and commonly used route for acetaminophen in infants who can tolerate oral intake. There is no ambiguity regarding how the medication should be delivered.

D. Dose: An 80 mg dose may be appropriate depending on the infant’s weight, as pediatric acetaminophen dosing is calculated at 10–15 mg/kg per dose. Although weight-based dosing should always be verified, the presence of a specific dose does not automatically require clarification unless it falls outside the safe range.