# Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants. The charge nurse reviews the tasks she gave the nursing attendants this morning. Which assignment should she take back and do herself?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629509  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse is the charge nurse of the 30-bed postpartum ward of a government hospital. Each shift is staffed by registered nurses and nursing attendants.

The charge nurse reviews the tasks she gave the nursing attendants this morning. Which assignment should she take back and do herself?

## 보기

1. Taking the blood pressure of a mother who reported a new headache an hour ago **✔ 정답**
2. Collecting a routine urine specimen from a mother 2 days after vaginal birth
3. Recording intake and output for a mother 1 day after cesarean birth whose catheter was removed this morning
4. Helping a mother 2 days after cesarean birth walk to the bathroom for the third time today

**정답: 1**

## 해설

Measuring vital signs is usually a delegable task, but the right circumstance for delegation is a stable client with a predictable outcome. A postpartum mother with a new headache has a changing condition that needs nursing assessment and judgment, so the nurse measures her blood pressure and assesses her herself. The other tasks are routine and predictable, with no new change in the mother's condition.

## 심화 해설

The assignment to take back
Measuring blood pressure is usually a task that a registered nurse can delegate to a nursing attendant. Delegation, however, depends not only on the task but also on the right circumstance: a stable client with a predictable outcome. The postpartum mother who reported a new headache an hour ago has a changing condition. A new headache after birth can be an early sign of postpartum preeclampsia or other serious problems. Because her condition is changing and needs nursing assessment and judgment, the charge nurse takes back the blood pressure measurement and assesses her herself.

The rights of delegation
Safe delegation is often taught as the five rights: the right task, the right circumstance, the right person, the right direction and communication, and the right supervision and evaluation. A task that is normally delegable can become non-delegable when the client is unstable or when the result will need immediate interpretation. In this case the blood pressure is not a routine check; it is part of assessing a new symptom, and assessment cannot be delegated to unlicensed staff.

Why the other assignments stay with the attendant

| Assignment | Why it is delegable |
| --- | --- |
| Routine urine specimen, 2 days after vaginal birth | Routine, predictable task in a stable client |
| Intake and output after catheter removal, 1 day after cesarean birth | Measuring and recording is routine; the nurse interprets the totals |
| Helping a mother walk to the bathroom for the third time today, 2 days after cesarean birth | She has already walked safely; routine care |

Watch out! The intake and output assignment may look like it needs a nurse because the catheter was just removed and the first voids matter. The nurse does need to evaluate whether the mother voids adequately, but the act of measuring and recording can still be delegated, as long as the attendant knows what to report. Interpretation stays with the nurse; data collection can be delegated.

What the nurse does next
The nurse measures the mother's blood pressure, asks about the severity and character of the headache, and checks for visual disturbance, epigastric pain, and other warning signs. She reviews the mother's prenatal and intrapartum blood pressure record and reports abnormal findings to the physician promptly. She also gives the nursing attendant clear direction on what changes in other mothers should be reported to her at once.

Exam takeaway
Delegate stable, routine, predictable tasks; keep assessment of any new or changing condition. Key point! In delegation items, look for words such as new, sudden, worsening, or just reported. They usually mark the client whose care should stay with the registered nurse.

## 임상 시나리오

Delegation on a Postpartum WardWhich task the charge nurse takes back
Delegate tasks only for a stable client with a predictable outcome. A task that is usually delegable becomes non-delegable when the condition changes.

A postpartum mother with a new headache needs nursing assessment: measure her blood pressure and check for other warning signs.

Routine specimens, intake and output recording, and help with walking for stable mothers can be delegated with clear reporting instructions.

CautionNever delegate assessment of a new symptom. The nurse may delegate data collection, but interpretation stays with the nurse.

## 핵심 개념

- **Delegation** — Transferring responsibility for a task to another competent person while the nurse stays accountable for the outcome.
- **Right circumstance** — The delegation principle that tasks are delegated only for stable clients with predictable outcomes.
- **Nursing attendant** — An unlicensed staff member who performs routine, predictable care under the supervision of a registered nurse.
- **Postpartum preeclampsia** — Preeclampsia that develops after birth, which may present with new headache or high blood pressure.

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