A nurse is caring for a 36-hr old infant.

The nurse is preparing the infant for phototherapy.

For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

A. Potassium level: Potassium measurement is used to assess electrolyte balance and kidney function, but it does not provide information about platelet function or clotting ability. It is not relevant for evaluating petechiae or ecchymoses.

B. Prealbumin: Prealbumin is a marker of nutritional status and protein intake. While important for overall health, it does not help identify the cause of bleeding disorders or thrombocytopenia.

C. Creatinine clearance: Creatinine clearance assesses renal function and is unrelated to platelet levels or coagulation abnormalities. It would not provide diagnostic information for clients presenting with bleeding manifestations.

D. Platelet count: A platelet count is essential for evaluating clients with generalized petechiae and ecchymoses because these signs suggest thrombocytopenia or platelet dysfunction. Measuring platelet levels helps determine the severity of the disorder and guides further diagnostic and therapeutic interventions.

A. An assistive personnel can evaluate a client's response to medication: Assistive personnel do not have the education or licensure to evaluate medication effects. They can perform delegated tasks such as vital signs or basic care, but assessment and evaluation of clinical responses remain within the RN’s scope of practice.

B. An RN can initiate the plan of care for a client on admission: Registered nurses are responsible for performing assessments, identifying nursing diagnoses, and developing an individualized plan of care upon admission. This is a core component of the RN’s legal scope of practice and requires professional judgment.

C. An RN can delegate blood administration to a licensed practical nurse: Blood administration is a high-risk procedure that generally cannot be delegated to an LPN in many states due to its complexity and potential for adverse reactions. The RN retains responsibility for administration and monitoring.

D. A licensed practical nurse can provide initial discharge instructions: Providing initial discharge instructions requires comprehensive assessment, education, and evaluation, which are within the RN’s scope of practice. LPNs may reinforce education but cannot independently provide initial instructions.