Question

Mrs. Peters just delivered her first baby two hours ago. Her vital signs one hour after delivery were B/P: 150/90, P: 110, R: 16. Mrs. Peters wants to walk to the nursery to see her baby. The nurse and the patient care assistant have worked together for approximately six months. The nurse decides not to delegate the task.

Which of the following MOST influenced this decision?

A) The task
B) The PCA's job description
C) Nursing judgment needed
D) Lack of adequate supervision

Answer 1

The nurse's decision not to delegate the task of accompanying Mrs. Peters to the nursery was most likely influenced by the need for nursing judgment due to Mrs. Peters' concerning post-delivery vital signs, requiring professional assessment and potential intervention.

Step-by-step explanation:

The decision by the nurse not to delegate the task of accompanying Mrs. Peters to see her baby in the nursery was most likely influenced by C) Nursing judgment needed. Mrs. Peters has recently delivered her first baby and her vital signs one hour after delivery were somewhat concerning, with a blood pressure (B/P) of 150/90, a pulse (P) of 110, and respiration (R) of 16. These vitals suggest that Mrs. Peters may be experiencing some complications post-delivery, such as hypertension or postpartum hemorrhage, which require close monitoring by a professional nurse.

The nurse's decision not to delegate the task involves clinical assessment, ongoing monitoring, and potential immediate intervention, which fall within the scope of nursing judgment and responsibility. In this case, the patient care assistant (PCA) may not have the necessary training or authority to respond to any sudden changes in Mrs. Peters' condition while walking to the nursery.