A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

Choice A rationale:

Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.

Choice A rationale:

Avoiding the use of draw sheets for repositioning is not a direct intervention for managing urinary incontinence. Draw sheets are typically used for repositioning and preventing pressure injuries. Managing urinary incontinence involves strategies such as toileting schedules, absorbent products, and perineal care.

Choice B rationale:

Limiting periods of sitting in a chair to 4 hours is a general guideline for preventing pressure ulcers in individuals with limited mobility, but it is not specific to managing urinary incontinence. Clients with urinary incontinence may need to sit in chairs for extended periods, and it is essential to address incontinence management separately.

Choice C rationale:

Using a no-rinse perineal cleanser after incontinence is an appropriate intervention for maintaining skin hygiene and preventing irritation in individuals with urinary incontinence. No-rinse cleansers are designed to clean the perineal area without the need for rinsing, making them convenient for incontinence care. Choice D