A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

A) Patient care technician: While a patient care technician (PCT) is an important part of the healthcare team, their role generally focuses on providing direct patient care tasks such as monitoring vital signs, assisting with activities of daily living, and supporting the nursing staff. They do not have the expertise to address complex medication interactions, so they are not the appropriate referral in this scenario.

B) Psychologist: A psychologist focuses on providing mental health support, including therapy and counseling. While medication interactions may be of concern in patients receiving psychiatric medications, a psychologist does not typically have the medical knowledge to assess or manage pharmacological interactions. The nurse would not make a referral to a psychologist for this issue.

C) Social worker: Social workers are important for addressing the social and emotional needs of patients, including helping with care coordination, support, and resources. However, they are not trained to evaluate or address medication interactions. This issue would be outside of their scope of practice.

D) Advanced practice nurse: An advanced practice nurse (APN), such as a nurse practitioner or clinical nurse specialist, has advanced training in diagnosing, managing, and prescribing medications. They are the most appropriate team member to assess the potential interactions of the client’s medications and make any necessary adjustments to their medication regimen. The nurse should refer the client to an APN for expertise in this area.

Administer phytonadione (Vitamin K): Contraindicated

There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.

Apply cool compress to the extremity: Anticipated

A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.

Elevate extremity: Anticipated

Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.

Suggest irrigating the IV catheter: Contraindicated

Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.

Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated

A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.

Send the catheter tip for culture: Anticipated

Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.