A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

A) *The client's partner visited earlier today for 2 hours: While this information is helpful for the personal context of the client, it is not essential to the clinical care of the client or a critical part of the handoff. The change-of-shift report should focus on relevant clinical information that affects ongoing care, such as treatment responses, medications, or changes in condition.

B) "The client reports pain is reduced when he is positioned on his side": This is important clinical information that should be included in the report. It provides insight into the client’s current comfort measures and pain management strategies. Sharing how the client’s pain can be alleviated will help the next nurse provide the most effective care and manage the client's comfort.

C) "The client received the prescribed antibiotic every 8 hours": While medication administration is an essential part of the report, this specific detail is unnecessary if the medication administration schedule is already part of the client's medical record or the nurse's medication administration documentation. The change-of-shift report should focus on whether the client has had any reactions, responses, or issues related to the medication, rather than simply repeating the schedule.

D) "The client's mother died 4 years ago from breast cancer": This personal history may be relevant to understanding the client's emotional well-being but is not essential in a clinical report unless it directly impacts current care. If the client's grief or family history affects their current health status (such as in the case of emotional distress, family health risks, or health behaviors), it may be relevant, but it's generally not a priority in a shift report unless it has immediate implications for care.

A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.

B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.

C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.

D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.