A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.
Which of the following actions should the nurse take first?

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice A rationale

Hypoglycemia is a common complication in newborns, especially those who are 8 hours old. The newborn’s body has not yet fully developed the ability to regulate blood sugar levels, leading to hypoglycemia.

Choice B rationale

Neonatal abstinence syndrome is typically seen in newborns exposed to addictive illegal or prescription drugs while in the mother’s womb. Without additional context, it’s not clear if this applies to the newborn in question.

Choice C rationale

Hyperbilirubinemia, or jaundice, is a condition that can occur in newborns, usually a few days after birth. However, it’s less likely to develop within the first 8 hours of life.

Choice D rationale

Drug withdrawal symptoms are similar to neonatal abstinence syndrome and occur in newborns who have been exposed to certain drugs while in the womb. Again, without additional context, it’s not clear if this applies to the newborn in question.