Level: Clinical
Difficulty: Medium
Subtopic: Newborn transition
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data include central cyanosis that does not improve with stimulation. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.