# Stage 5 — Take action. Place the five action clusters in the safest sequence for this six-month well-child visit. Some tasks may overlap. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=en > language: en > subject: Assignment/Delegation/Supervision > category: HPM ## Question Stage 5 — Take action. Place the five action clusters in the safest sequence for this six-month well-child visit. Some tasks may overlap. Use individualized demonstration and teach-back for the empty supine-start sleep space, rear-facing seat, walker removal, stair protection, appropriate primary milk and iron-rich foods, and supervised texture-safe feeding. After products, intervals, contraindications, precautions, season, and health status are verified, administer the vaccines ordered for today and schedule any additional series or seasonal dose still due. Document growth and surveillance, vaccine products and follow-up doses, iron plan and screening window, demonstrated teach-back, equipment changes, unresolved barriers, next visit, and accountable handoff. Assess growth trajectory and current development; ask about lost skills or concerns; reconcile feeding and iron sources, vaccine products and dates, sleep, car-seat use, walker, stairs, and food preparation. Share the assessment, acknowledge developmental strengths, and prioritize the highest-consequence modifiable risks with the parents, including sleep setup, travel direction, walker and stair access, and cow-milk replacement. ## Explanation Safest sequence: 2 → 5 → 4 → 3 → 1 Start with a complete growth, developmental, nutrition, immunization, and safety assessment (choice 2). Partner with the parents to acknowledge strengths and prioritize the highest-consequence risks (choice 5). Give vaccines only after the exact record and current indications are reconciled (choice 4). Build the home plan through demonstration and teach-back, including future screening and dose dates (choice 3). Complete documentation and accountable follow-up last (choice 1), while recognizing that documentation occurs throughout. ## In-depth explanation 1 — Know the actual baseline Do not teach from assumptions. The nurse needs growth and developmental context, the exact vaccine series, the current iron sources, and the family's real sleep and equipment practices. 2 — Set priorities with the family Strength-based discussion preserves partnership while making immediate sleep, travel, stair, and feeding risks explicit. 3 — Complete indicated prevention Reconciliation precedes vaccine administration because product and interval details can change which doses are due. 4 and 5 — Convert advice into action Demonstration, teach-back, dates, barrier resolution, and documentation close the loop more reliably than a generic handout. ## Clinical scenario Scenario (Stage 5 — Take action) The nurse structures the visit so routine prevention and immediate risk reduction are both completed accurately. ## Key concepts - **Comprehensive well-child assessment** — Integrated growth, development, nutrition, immunization, oral health, sleep, injury-prevention, family-priority, and social-risk review. - **Product-specific vaccine decision** — A dose decision based on documented vaccine product, prior dose, age, interval, season, health condition, and current schedule notes. - **Barrier-aware safety plan** — A concrete change with equipment, timing, responsible person, follow-up, and help for cost or access barriers when needed. ## Related questions - [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en) - [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=360523&lang=en) - [A 78-year-old male client with end-stage pancreatic cancer is enrolled in inpatient hospic…](https://mymerci.kr/pages/nclex_q.php?qn_id=362322&lang=en) - [A nurse on a medical-surgical unit is starting a 0700 round and reviews these four assigne…](https://mymerci.kr/pages/nclex_q.php?qn_id=362403&lang=en) - [An RN is assigning care on a medical-surgical unit to an LPN/VN and a trained unlicensed a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362464&lang=en) - [A registered nurse on a medical-surgical unit is assigning tasks to a licensed practical n…](https://mymerci.kr/pages/nclex_q.php?qn_id=363932&lang=en) - [A charge nurse on a medical-surgical unit is making assignments for the day shift. The tea…](https://mymerci.kr/pages/nclex_q.php?qn_id=363953&lang=en) - [A nurse manager is reviewing situations from the past week to identify potential HIPAA Pri…](https://mymerci.kr/pages/nclex_q.php?qn_id=364050&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=373877&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._