A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift.
Which of the following statements should the nurse document on the incident report form?

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

• A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.
• B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.
• C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.
• D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.