A nurse is caring for a toddler.
The nurse’s observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next?

The correct answer is Choice A

Choice A rationale: Ensuring that the mother calls and the nurse takes the baby to the room maintains security and safety protocols. It prevents unauthorized individuals from handling the infant, thus minimizing the risk of abduction or harm.

Choice B rationale: Showing photo identification alone is not sufficient to ensure the safety of the newborn. The nurse should directly handle the transfer of the baby to maintain strict security measures and verify the proper identification in the process.

Choice C rationale: Allowing someone to push the baby in a wheeled bassinet without proper authorization and identification verification does not adhere to safety protocols. The nurse should always verify and manage the transfer to ensure the infant’s security.

Choice D rationale: Carrying the grandchild to the room without adequate identification verification and authorization does not follow safety protocols. The nurse should always be involved in the transfer to prevent any security breaches and ensure the infant’s safety.

Choice A rationale

Celery sticks are safe to consume while on a monoamine oxidase inhibitor (MAOI) medication. They do not contain tyramine, which can cause a hypertensive crisis if consumed while taking an MAOI8.

Choice B rationale

Sliced apples are also safe to consume while on an MAOI medication. They do not contain tyramine.

Choice C rationale

Bologna sandwiches should be avoided while on an MAOI medication. Bologna is a type of processed meat that can be high in tyramine.

Choice D rationale

A glass of whole milk is safe to consume while on an MAOI medication. It does not contain high levels of tyramine.