The nurse reviews the client's test results.

Exhibits

Complete the following sentence by using the list of options.

The nurse should wear

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and

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A. "I should enable the airbag when my baby is in the front seat of the car." Airbags deploy with significant force and can cause severe injury or fatal trauma to an infant in a car seat, especially if placed in the front seat. The safest position for an infant is in the back seat, rear-facing, as this provides the best protection in the event of a crash. If the front seat must be used, the airbag should be deactivated to prevent impact injuries.
B. "I should position the car seat's retainer clip at the level of my baby's belly button." The car seat’s retainer clip should be positioned at armpit level to properly secure the harness and keep the baby restrained during a collision. If the clip is placed too low, such as at the belly button, the harness straps may not fit snugly around the shoulders, increasing the risk of the baby slipping out of the seat upon impact.
C. "I should place my baby in the car seat at a 90-degree angle." A 90-degree angle is too upright for a newborn and can lead to airway obstruction due to the infant's weak neck muscles and large head size. The car seat should be reclined at approximately 45 degrees to maintain an open airway and prevent the baby’s head from falling forward, which could restrict breathing and cause positional asphyxia.
D. "I should keep my baby rear-facing in the car seat until she is 2 years old." Rear-facing car seats provide optimal protection by supporting the baby’s head, neck, and spine in the event of a crash, reducing the risk of serious injury. The American Academy of Pediatrics recommends keeping infants in a rear-facing position until at least the age of 2 or until they exceed the car seat's height and weight limits. This positioning distributes crash forces more evenly across the child's body, minimizing the risk of spinal cord and head injuries.

• Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
• Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
• Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
• Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

• Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
• Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.