A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Choice A reason: Placing the client in semi-Fowler’s position for postoperative assessment is appropriate, promoting lung expansion and reducing aspiration risk. This aligns with standard care, supporting respiratory function and comfort, requiring no further instruction as it reflects safe, evidence-based practice.
Choice B reason: Auscultating lungs without lifting the gown may reduce clarity but is not unsafe. It preserves modesty and is acceptable if effective. While lifting the gown is preferred, this action poses minimal risk, requiring less instruction compared to errors with immediate safety implications.
Choice C reason: Administering an enema without checking for contraindications, like bowel obstruction, risks complications such as perforation. This reflects poor assessment, necessitating instruction to ensure the nurse verifies patient safety and chart details before invasive procedures to prevent harm.
Choice D reason: Checking vital signs before cardiac medication is correct, ensuring safety (e.g., withholding beta-blockers for low heart rate). This follows pharmacological protocols, requiring no instruction, as it demonstrates competence in safe medication administration practices on a medical-surgical unit.

Choice A reason: Referring to a mental health clinic addresses potential emotional distress but not the adolescent’s primary concern of affordability. Pregnancy increases psychological stress, but financial barriers to prenatal care are critical. This action fails to ensure access to medical resources, essential for maternal and fetal health in adolescent pregnancy.
Choice B reason: Contacting the adolescent’s parent risks breaching confidentiality, depending on legal guidelines, and does not address financial concerns directly. Family dynamics may complicate support, and without consent, this action could increase stress, failing to provide immediate healthcare access critical for a healthy pregnancy outcome.
Choice C reason: Assisting with Medicaid application directly addresses financial concerns, ensuring access to prenatal care, delivery, and postpartum support. Medicaid reduces risks like preterm birth by covering medical and nutritional needs, critical for adolescent mothers with limited resources, aligning with public health goals for maternal-fetal well-being.
Choice D reason: Advising adoption is premature and overlooks the adolescent’s autonomy. Adoption requires extensive counseling, not immediate recommendation. It fails to address healthcare access, critical for a healthy pregnancy. This approach dismisses financial solutions, potentially increasing stress and undermining informed decision-making in pregnancy.