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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse (PN) is assisting with a 2-week-old neonate's well-child visit at a pediatric clinic. Which of the following actions by the PN are within the scope of practice and demonstrate safe care? (Select all that apply.)

  1. Verifying the neonate's identity using two unique identifiers before administering any prescribed medications.Answer
  2. Documenting the presence of a symmetrical startle response to a loud noise as an expected Moro reflex.Answer
  3. Immediately reporting a capillary refill time of 5 seconds and a mottled skin appearance to the registered nurse.Answer
  4. D
    Administering scheduled vaccines based solely on the immunization record without assessing for acute illnesses or contraindications.
  5. E
    Reporting a suspected developmental delay to the provider because the neonate cannot independently roll from the abdomen to the back.
  6. F
    Asking the exhausted parent, "Why don't you try sleeping when the baby sleeps to avoid feeling so tired?"

Answer

The correct actions are verifying the neonate's identity with two identifiers, documenting the Moro reflex as an expected finding, and reporting a delayed capillary refill time to the registered nurse.
Verifying patient identity with two identifiers ensures fundamental medication safety. The Moro (startle) reflex is a normal, expected neurologic response in a 2-week-old neonate that should simply be documented. A capillary refill time of 5 seconds paired with mottled skin indicates poor perfusion and potential shock, requiring immediate escalation to the registered nurse.

Step-by-Step Solution

1
Evaluate each action for adherence to safety standards and the practical nurse scope of practice.
Identified actions requiring basic data collection, safety verification, and immediate reporting of physiological abnormalities.
The practical nurse must differentiate between normal neonatal findings and critical abnormalities requiring registered nurse intervention.
2
Analyze the developmental and physiological expectations for a 2-week-old neonate.
The Moro reflex is recognized as normal, whereas the inability to roll over is also normal at this age. A prolonged capillary refill is abnormal.
Accurate developmental and physical data collection prevents false reporting of delays and ensures timely escalation of true emergencies.
3
Assess communication techniques and procedural safety protocols.
Using two patient identifiers is a mandatory safety standard. Conversely, asking 'why' questions is non-therapeutic and inappropriate.
Ensuring correct patient identification and utilizing therapeutic communication are core competencies required for safe practice.

Key Concept

Practical Nursing Scope of Practice in Newborn Care and Safety
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Topics

Ante/Intra/Postpartum and Newborn Care

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