A nurse is caring for a newborn.

Vital Signs.

0640:. Temperature 36.7°C (98.1° F) axillary.

Heart rate 154/min.

Respiratory rate 68/min.

BP 72/48 mm Hg. 0650:. Heart rate 156/min.

Respiratory rate 72/min.

0700:. Temperature 37° C (98.6° F) axillary.

Heart rate 156/min.

Respiratory rate 76/min.

Admission Assessment.

0630:. Newborn delivered via cesarean birth under spinal anesthesia at. 0630.

Amniotic fluid clear.

0631:. 1-min Apgar score 7. 0636:. 5-min Apgar score 9. Newborn transferred to nursery.

Nurses' Notes.

0640:. Weight 4200 gm (9 Ib 4 oz), head circumference 35.5 cm (14 in). Respiratory rate 68/min, with mild grunting.

0650:. Respiratory rate 72/min, with mild grunting.

0700:. Respiratory rate 76/min, with moderate grunting and mild.

intercostal retractions.

Drag words from the choices below to fill in each blank in the following.

sentence.

The client is at risk for developing Target 1 and Target 2.

Explanation: MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in various parts of the body. The nurse should wear a gown when assisting the client with personal hygiene to prevent contact transmission of MRSA to other clients or staff members. The nurse should also wear gloves and a mask and perform hand hygiene before and after contact with the client or their environment. The nurse should remove personal protective equipment before leaving the client's room and dispose of it properly to avoid contamination of other areas or surfaces. Negative air pressure is not required for MRSA isolation because it is not an airborne infection. The client's visitors should not be restricted, but they should be educated on the proper use of personal protective equipment and hand hygiene when visiting the client.

The correct answer is D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.

Choice A reason: Storing a unit of blood at room temperature for 1 hour prior to the infusion is not recommended. Blood products should be kept refrigerated until just before the transfusion to minimize the risk of bacterial contamination. The recommended storage temperature for packed RBCs is 1-6°C. If blood is left at room temperature, it should be infused within 30 minutes to ensure safety.

Choice B reason: Ensuring that the transfusion is completed within 6 hours is not correct. The standard practice is to complete a blood transfusion over 2 to 4 hours, depending on the volume and the patient’s condition. This is to reduce the risk of bacterial growth and transfusion reactions. Prolonging the transfusion time beyond 4 hours increases the risk of bacterial contamination and can compromise the efficacy of the transfused red blood cells.

Choice C reason: Obtaining venous access using a 22-gauge needle is not ideal for a transfusion of packed RBCs. A larger bore needle, typically an 18-gauge or 20-gauge, is preferred to ensure adequate flow of the viscous packed RBCs and to prevent hemolysis. The smaller the gauge number, the larger the needle diameter, so a 22-gauge needle might be too small and could damage the red blood cells during the transfusion.

Choice D reason: Using a solution of 0.9% sodium chloride to flush the transfusion tubing is the correct action. Normal saline is isotonic and is the only fluid compatible with packed RBCs. It is used to prime the transfusion set and to flush the line before and after the transfusion to prevent hemolysis and clotting within the tubing.