A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

Rationale:

A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.

B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily.

C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.

D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights.

Rationale:

A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.

B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.

C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.

D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.

E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.