A nurse is caring for a newborn.

Exhibits

Newborn transferred to nursery.

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing

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and

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A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.