A nurse is assessing a newborn 1 hour after birth.
The nurse recognizes that which of the following respiratory rates is within the expected reference range for a newborn?

Choice A rationale

While altered mucus membranes can occur in patients with Crohn’s disease, it is not typically the primary nursing assessment.

Choice B rationale

Fluid volume deficit can occur in patients with Crohn’s disease due to diarrhea, a common symptom of the disease. However, it is not typically the primary nursing assessment.

Choice C rationale

Nutrition should be prioritized in the nursing assessment for a patient diagnosed with Crohn’s disease. Malnutrition can occur due to decreased appetite, malabsorption of nutrients, and increased nutritional needs due to inflammation.

Choice D rationale

While skin integrity can be a concern in patients with Crohn’s disease, particularly those with fistulas, it is not typically the primary nursing assessment.

Choice A rationale

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.