A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

Choice A rationale:

Colostrum, the initial breast milk produced after childbirth, is crucial for a newborn's health because it contains a high concentration of antibodies, also known as immunoglobulins (IgA), which provide passive immunity to the baby. These antibodies are essential because a newborn's immune system is immature and not yet capable of producing its antibodies. IgA antibodies in colostrum help protect the baby against various infections, including respiratory and gastrointestinal illnesses. Therefore, choice A is the correct answer as it accurately reflects the importance of colostrum in providing immune protection for the newborn.

Choice B rationale:

Colostrum does not primarily provide vitamin K. While vitamin K is essential for newborns to prevent bleeding disorders, it is not the primary function of colostrum. Colostrum's primary role is to provide immune protection.

Choice C rationale:

Colostrum does contain trace amounts of iron, but its iron content is not the primary reason for its importance. Iron stores in a newborn's body are typically established during the third trimester of pregnancy, and colostrum is not a significant source of iron for the baby. The primary role of colostrum is to provide antibodies, not iron.

Choice D rationale:

Colostrum does not contain a natural diuretic. Its purpose is not to stimulate the newborn to void. Instead, it focuses on providing immune protection and essential nutrients for the baby's initial growth and development.