A nurse is teaching the guardian of a newborn about car seat safety.
Which of the following statements by the guardian indicates an understanding of the teaching?

Choice A rationale

Reporting the observation to the immediate supervisor is the most appropriate and ethical action. The nurse is a mandated reporter for such events within the healthcare setting. The supervisor, in their administrative role, is responsible for initiating a formal investigation into the matter, ensuring due process, and taking necessary disciplinary action according to institutional policy. This approach protects both the client and the nurse, who is acting on observed evidence, and maintains a chain of command.

Choice B rationale

Confronting the assistive personnel (AP) directly is an inappropriate and potentially unsafe action. This approach could escalate the situation, lead to a hostile confrontation, and create an unsafe work environment. The nurse's role is not to act as a law enforcement officer or to administer disciplinary action. The proper channel for addressing a suspected theft is through the established reporting structure, which involves informing the immediate supervisor. This maintains professional boundaries and ensures a fair and impartial investigation.

Choice C rationale

Telling the client that the assistive personnel (AP) took their watch is premature and unprofessional. The nurse has only observed the AP with a watch, but has not yet confirmed it is the client's. Making such an accusation directly to the client could be slanderous, cause emotional distress, and is not a factual statement. The proper procedure is to report the observation to the supervisor and allow the official investigation to proceed, which will determine the facts before any conclusions are drawn or communicated.

Choice D rationale

Calling security before the assistive personnel (AP) leaves the building is an excessive and premature action. The nurse's role is to report concerns to the immediate supervisor, who will then follow the proper institutional procedures, which may include contacting security if deemed necessary. Bypassing the chain of command and taking unilateral action could create a chaotic and unmanaged situation, potentially infringing on the AP's rights. The supervisor is the designated authority to manage such incidents and coordinate with other departments as needed. *.

Choice A rationale

Looping the tubing so it is lower than the collection bag creates a dependent loop, which can cause urine to pool and create a backflow into the bladder. This stasis of urine provides a fertile environment for bacteria to multiply and ascend the urinary tract, significantly increasing the client's risk for a urinary tract infection. The bag should always be below the bladder.

Choice B rationale

Keeping the urinary bag at bladder level or higher when ambulating is a significant risk factor for urinary tract infections. This positioning allows for the backflow of urine from the collection bag into the bladder. The retrograde flow of urine can transport bacteria into the sterile bladder, leading to bacterial colonization and a subsequent infection.

Choice C rationale

Securing the catheter to the client's thigh is a crucial intervention for minimizing the risk of a UTI. It prevents movement and traction on the catheter at the urethral meatus. This minimizes urethral tissue irritation and micro-trauma, which can serve as entry points for bacteria. It also reduces tension on the catheter, preventing accidental dislodgement.

Choice D rationale

Disconnecting the tubing connections to obtain a urinary sample is a high-risk action for introducing microorganisms. Each disconnection breaks the closed, sterile system, allowing airborne bacteria or contaminants from the external environment to enter the catheter and tubing. This breach of sterility can lead to bacterial ascension into the bladder, causing a urinary tract infection. *.