A nursery nurse is attending the birth of a post-term infant.

Exhibits

Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

Rationale:
A. "This medication can increase your risk for osteoporosis.": Long-term warfarin use may affect bone density slightly, but this is not the primary teaching point for safety and daily management. It is less immediately relevant than bleeding risk.

B. "This medication can cause hearing loss.": Warfarin is not associated with ototoxicity or hearing loss; this statement does not reflect a known adverse effect of the medication.

C. "Avoid drinking cranberry juice while taking this medication.": Cranberry products can interact with warfarin and increase the risk of bleeding by potentiating its anticoagulant effect. Clients should be advised to avoid or limit cranberry intake to maintain safe INR levels.

D. "Increase your intake of foods high in vitamin K while taking this medication.": Consuming consistent amounts of vitamin K is important, but the client does not need to increase intake. Sudden increases can counteract warfarin’s effect; the emphasis is on maintaining a stable vitamin K intake.

Rationale:
A. Skin warm and dry: Warm, dry skin indicates adequate circulation and fluid balance. In fluid overload, the skin is often cool and moist due to peripheral vasodilation and increased interstitial fluid. Therefore, this finding is not consistent with overhydration.

B. Respiratory rate 30/min: Tachypnea is a key indicator of fluid overload because excess fluid can accumulate in the lungs, leading to pulmonary congestion and decreased gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide.

C. Heart rate 60/min: A normal heart rate suggests stable cardiovascular status. Fluid overload typically causes tachycardia as the heart works harder to manage increased circulatory volume, not a normal or bradycardic rate.

D. Tenting skin turgor: Tenting indicates dehydration, not fluid overload. In overhydration, the skin is usually taut and edematous due to excess interstitial fluid accumulation rather than loss of elasticity.