A nurse is reviewing the medication record of an infant. The nurse notes a new prescription for acetaminophen 80 mg PO for a temperature above 38.5° C (101.3° F). Which of the following should the nurse clarify with the provider before administering the medication?

A. Plan of care: The plan of care is developed and updated by licensed nursing staff and other providers. Assistive personnel (AP) are not authorized to document assessments, interventions, or changes in the plan of care, as this requires professional judgment and accountability.

B. Graphic record: APs can document routine, objective data such as vital signs, intake and output, and other measurable observations in the graphic or flow sheet section of the EHR. This allows for accurate tracking of trends while remaining within their scope of practice.

C. Nurses' notes: Nurses’ notes require professional assessment, analysis, and evaluation of client responses to care. APs do not have the licensure to make these judgments, so they should not document in this section.

D. Discharge teaching: Documentation of discharge teaching reflects the nurse’s evaluation of client understanding and education provided, which is a licensed nursing responsibility. APs can reinforce teaching but are not authorized to document it as part of the official discharge record.

A. Apply continuous pulse oximeter: The infant’s oxygen saturation has declined from 94% to 92% with increasing respiratory distress and tachypnea, indicating worsening gas exchange. Continuous pulse oximetry is essential to monitor for hypoxemia in bronchiolitis, where airway inflammation and mucus plugging impair ventilation. Early detection of desaturation allows prompt oxygen administration to prevent respiratory failure.

B. Reinforce instructions for parent regarding use of breast pump to express milk: Although maintaining nutrition is important, the infant’s respiratory rate has increased to 70/min, and oral intake is restricted when the rate exceeds 60/min due to aspiration risk. Education about breast pumping does not address the immediate priority of airway and breathing compromise.

C. Administer acetaminophen: The infant has a temperature of 38.7°C, which meets criteria for antipyretic administration. However, fever management is secondary to stabilizing airway and breathing in a child showing escalating respiratory distress and declining oxygen saturation.

D. Assist with insertion of peripheral intravenous access device: The infant demonstrates poor breastfeeding, tachypnea, and signs of mild dehydration, increasing the risk of fluid deficit. IV access is necessary to initiate the prescribed maintenance fluids and maintain hydration when oral intake is unsafe. Establishing vascular access also prepares for potential rapid deterioration.

E. Suction the nares: Thick nasal secretions contribute to airway obstruction, especially in infants who are obligate nose breathers. Suctioning the nares reduces upper airway resistance, improves airflow, and may decrease work of breathing. Clearing secretions directly addresses the immediate respiratory compromise seen in bronchiolitis.

F. Apply urine collection bag: A urine specimen for culture is ordered, but obtaining it does not take priority over airway stabilization and oxygenation. While monitoring output is important for hydration status, it is not the most urgent intervention given the infant’s respiratory deterioration.

G. Obtain blood cultures: Blood cultures are indicated to evaluate for possible bacterial infection; however, they are not the immediate priority in a child with worsening respiratory distress. Stabilizing airway, breathing, and circulation takes precedence before diagnostic specimen collection.