A nurse has assessed the skin of a newborn with the AWHONN Neonatal Skin Condition Score Tool and determines that her patient has a score of 3. What action by the nurse is most appropriate?
A.
Document the findings and continue to monitor.
B.
Elevate the child's lower extremities on pillows.
C.
Implement pressure ulcer prevention measures.
D.
Request a consultation by the wound care nurse.
ANS: A
This is a perfect score using this tool. The nurse should document the findings and continue to monitor per agency protocol. None of the other actions is required.
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