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 prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.

Choice B rationale:

This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.

Choice C rationale:

This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.

Choice D rationale:

Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.

The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.