A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?

A. An assistive personnel weighs and bathes the newborn in an empty client room: While this may not be ideal practice depending on facility policy, it does not necessarily indicate a security threat unless the newborn is removed from secured areas without authorization.

B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: It is common for nurses to transport newborns for necessary procedures, provided proper identification protocols are followed. This situation does not automatically trigger a security alert.

C. The caregiver and newborn have matching hospital identification bracelets: Matching ID bracelets are part of the standard safety protocol to ensure correct infant identification and prevent abduction. This situation demonstrates proper security measures.

D. A hospital volunteer leaves the unit with the newborn to allow the caregiver to rest: Volunteers are not authorized to transport newborns outside of secured areas. This action represents a serious breach of security and requires the immediate initiation of a security alert to prevent potential abduction or harm.

• Prepare client for insertion of 18-gauge peripheral IV prior to surgery: A large-bore IV catheter, such as an 18-gauge, is necessary before surgery to ensure rapid administration of fluids, medications, or blood products if needed during the procedure. It is a measure to support hemodynamic stability during anesthesia and surgery.
• Administer Rh, D immune globin prior to surgery: The client's blood type is B negative. Because an ectopic pregnancy involves fetal tissue, and there's a potential for fetal-maternal blood mixing during the surgery, administering Rh(D) immune globulin (RhoGAM) is crucial to prevent Rh sensitization in Rh-negative women who may be carrying an Rh-positive fetus. This is typically given within 72 hours of a potential sensitizing event.
• Obtain a complete blood count: A CBC is critical to assess hemoglobin, hematocrit, and platelet levels before surgery. This helps the healthcare team anticipate the risk of bleeding and determine if transfusions might be necessary during or after the laparoscopic procedure.
• Explain the surgical procedure to the client: Explaining the surgical procedure is the provider's responsibility, not the nurse's role. The nurse can reinforce teaching and answer basic questions but should not be the primary person explaining the procedure or obtaining informed consent.
• Remind client to be NPO prior to surgery: Maintaining NPO status is essential to reduce the risk of aspiration during anesthesia. The client should avoid eating or drinking for a specified time before surgery, following the facility's preoperative protocol.
• Verify consent form is signed by the client: Verifying that the informed consent form is properly signed is a crucial nursing responsibility before surgery. It ensures legal compliance and confirms that the client has been informed about the procedure, risks, and alternatives.