The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

The correct answer is Choice C. Place the ID bands on the infant and mother.

Choice A rationale:

While obtaining the infant's vital signs is important, it is not the priority action before transporting the baby to the nursery. Placing ID bands on the infant and mother ensures proper identification and prevents mix-ups during transportation, which is crucial in the nursery setting.

Choice B rationale:

Administering vitamin K injection is also essential but not the immediate priority before transporting the baby. Vitamin K administration helps prevent bleeding disorders in newborns, but ensuring proper identification and security come first.

Choice C rationale:

The correct choice. Placing ID bands on the infant and mother is the most important action before transporting the baby to the nursery. This step ensures accurate identification and matching between the baby and the mother, preventing any confusion or errors in the hospital setting.

Choice D rationale:

Observing the infant latching onto the breast is important for promoting breastfeeding, but it can be done after ensuring proper identification and safety measures have been taken.

Correct Answer: B. Joint pain.

Choice B rationale:

Joint pain is the most common symptom experienced by individuals during a sickle cell crisis. The misshapen red blood cells can block blood flow to joints, leading to severe pain and inflammation. Joint pain is a hallmark sign of a sickle cell crisis, and managing pain is a critical aspect of caring for these patients.

Choice A rationale:

Decreased hemoglobin is not the expected symptom during a sickle cell crisis. A sickle cell crisis is characterized by sudden and severe pain due to the misshapen red blood cells blocking blood flow and causing tissue damage. While a sickle cell crisis can lead to anemia, the child experiencing the crisis would be more likely to describe pain and not specifically mention decreased hemoglobin.

Choice C rationale:

Infection is not a typical symptom experienced during a sickle cell crisis. While sickle cell disease can increase the risk of infections, the crisis itself primarily manifests as acute pain due to vaso-occlusion.

Choice D rationale:

Fatigue may be experienced by individuals with sickle cell disease, especially during or after a crisis, but it is not the most likely symptom they would describe during a sickle cell crisis. The hallmark symptom of a sickle cell crisis is severe pain.