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.

Choice A rationale:

The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.

Choice B rationale:

Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.

Choice C rationale:

The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.

Choice D rationale:

A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.

The correct answer is Choice B: Speak in a normal voice at a natural pace.

Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.

Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.

Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.

Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.