A mental health nurse is caring for a client who recently attempted to self-harm. The client states, "I wish I were dead." Which of the following responses should the nurse make?

Rationale for Correct Choices

• Swaddle the newborn in a blanket: Swaddling helps reduce heat loss through convection and evaporation, which is essential for a preterm newborn who has limited brown fat and poor thermoregulation. Maintaining warmth helps stabilize respiratory effort and metabolic demand. It is appropriate because the newborn’s temperature is below normal and continues to trend low.

• Dry the newborn: Drying reduces evaporative heat loss, which is a major risk immediately after birth, especially for late-preterm infants. Removing moisture from the skin supports temperature stabilization and reduces metabolic stress. This action is essential when temperatures remain below 36.5° C.

• Monitor the newborn’s vital signs: Frequent monitoring helps detect changes in temperature, heart rate, and respiratory drive, all of which can fluctuate rapidly in late-preterm newborns. Continuous monitoring allows the nurse to evaluate whether interventions for temperature and oxygenation are effective.

• Place the newborn under a radiant warmer: A radiant warmer provides controlled heat to support thermoregulation in preterm newborns who cannot maintain temperature independently. With temperatures at 36° C and 36.4° C, thermoregulation support is indicated to prevent cold stress. Radiant warming also helps stabilize oxygenation and metabolic rate.

• Administer free-flow oxygen: The newborn’s oxygen saturation is low at 90–91% on room air, indicating mild respiratory compromise. Providing free-flow oxygen improves oxygenation without requiring invasive airway management. This is appropriate for a newborn with increased respiratory effort but stable heart rate.

• Clear airway using bulb suction: Bulb suctioning is appropriate if secretions contribute to increased respiratory rate or difficulty maintaining saturation. Clearing the airway helps remove mucus that may impair airflow in preterm newborns. It supports spontaneous breathing and improves oxygenation.

Rationale for Incorrect Choices

• Initiate chest compressions: Chest compressions are only indicated when the newborn’s heart rate is below 60/min after at least 30 seconds of effective ventilation. This newborn’s heart rate is between 124–144/min, which is well above the threshold for resuscitation. Chest compressions are unnecessary and inappropriate for this clinical status.

• Place the newborn in prone position: Prone positioning is not recommended for routine stabilization and can compromise airway patency in a newborn requiring continuous monitoring. Supine or side-lying positioning reduces risk of airway obstruction and allows optimal chest expansion. Prone positioning increases risk for respiratory compromise in the acute period.

Rationale

• Genitourinary findings: Intermittent sensations of "squeezing or spasm" in the bladder or urinary tract are typical in multiple sclerosis due to autonomic nervous system involvement and demyelination affecting bladder control. These symptoms are less common in ALS, which primarily affects motor neurons without early autonomic involvement.

• Report about gait: Episodes of leg weakness and balance issues can occur in both ALS and MS. ALS causes progressive motor weakness affecting gait due to upper and lower motor neuron degeneration. MS can cause intermittent gait disturbances from demyelination in the central nervous system, often with exacerbations and remissions.

• Vision disturbance: Intermittent double vision is consistent with MS, reflecting demyelination of cranial nerves or the optic pathways. Visual symptoms, including diplopia or optic neuritis, are hallmark early signs of MS. ALS typically does not involve vision, making this symptom specific to MS.

• Energy level: Fatigue lasting more than 4 months aligns with MS, which frequently causes persistent fatigue due to both neurological dysfunction and immune-mediated inflammation. ALS may lead to fatigue later in disease progression, but early chronic fatigue is more characteristic of MS.