A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.

B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.

C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.

D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).

E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).

F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.