A nurse is working on a facility's postpartum unit. For which of the following situations should the nurse initiate a security alert?
An employee is using a basinet to move a newborn from the nursery to the mother's room.
An individual is wearing an identification badge without a photograph.
A parent requests that an individual who plans to perform tests on their newborn be identified.
A newborn in a client's room is missing one of its identification bands.
The Correct Answer is D
A. An employee is using a bassinet to move a newborn from the nursery to the mother's room: Transporting a newborn in a bassinet within the unit is standard practice and does not indicate a security breach. Employees are trained to move infants safely between nursery and mother’s room as part of routine care.
B. An individual is wearing an identification badge without a photograph: While a photo badge is important for verifying identity, encountering someone without a photo badge does not immediately indicate a security threat. The nurse should verify the individual’s credentials, but it does not warrant activating a facility-wide security alert.
C. A parent requests that an individual who plans to perform tests on their newborn be identified: This situation involves parental verification of personnel, which is part of routine patient rights and safety practices. It does not represent a security breach requiring an alert, but staff should provide appropriate identification and explanations.
D. A newborn in a client's room is missing one of its identification bands: Missing identification bands on a newborn is a serious safety concern and indicates a potential risk for misidentification or abduction. This situation requires immediate initiation of a security alert according to hospital policy to protect the infant and notify appropriate security personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will cleanse the stoma site gently with an antiseptic solution.": The stoma and surrounding skin should be cleaned with warm water and mild, non-irritating soap if needed. Antiseptic solutions can irritate the skin and damage the stoma, so this is not recommended.
B. "I will contact my doctor right away if my stoma is red.": Mild redness around the stoma can be normal due to friction or recent appliance changes. Immediate contact is warranted only if there are additional signs of infection, severe irritation, or unusual bleeding. Routine redness alone is not necessarily a cause for urgent concern.
C. "I will cut the wafer opening 1 inch bigger than my stoma.": The appliance opening should closely fit the stoma, typically allowing a 1/8 to 1/4 inch clearance. Cutting the wafer 1 inch larger would leave skin exposed to effluent, increasing the risk of irritation, breakdown, and leakage.
D. "I will empty the colostomy bag when it is one-half full.": Emptying the colostomy bag when it is about one-half to two-thirds full helps prevent leakage and reduces the weight on the appliance, which supports skin integrity and ensures proper functioning. This statement reflects correct understanding of colostomy care.
Correct Answer is B
Explanation
A. FACES scale: The FACES pain scale relies on the child’s ability to recognize and point to facial expressions that match their pain intensity. It is appropriate for children aged 3 years and older, as it requires cognitive and emotional development beyond that of a 3-month-old infant.
B. FLACC scale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is designed to assess pain in infants and young children who cannot verbalize their discomfort. It evaluates observable behaviors, such as facial expressions, leg movement, body activity, crying, and consolability, providing an objective measure of pain in preverbal children.
C. Color tool: Color-based pain assessment tools typically require the child to associate colors with pain intensity. This method is suitable for older children with sufficient cognitive development to understand abstract representations, not for infants.
D. Numeric scale: Numeric rating scales require the child to understand and quantify pain on a scale of 0 to 10. This tool is inappropriate for a 3-month-old, as infants lack the developmental capacity to comprehend numerical concepts or self-report pain.
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