Exhibits

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Assessment	Findings
Nurses' Notes	Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted.

	FHR baseline 138, minimal variability. No further reports of burning with urination.
Laboratory Results	WBC 12,000/mm2 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Vital Signs	Temperature 37.1° C (98.7° F) Blood pressure 120/78 mm Hg

A. Sodium phosphate is commonly used as a bowel prep before a colonoscopy, and there is no immediate concern in this situation unless the client is showing signs of dehydration or electrolyte imbalances.
B. A positive Mantoux test induration indicates exposure to tuberculosis, which should be further evaluated, but it is not immediately urgent.
C. An increase in urinary frequency while taking bumetanide (a diuretic) is expected and should be monitored, but it is not a cause for alarm unless accompanied by other signs of dehydration or electrolyte imbalance.
D. Warfarin and breastfeeding require careful monitoring, as warfarin can pass into breast milk and affect the infant. The nurse should follow up on this situation to ensure the safety of both the mother and infant.

The client is at risk for developing transient tachypnea of the newborn andhypoglycemia.

Rationale

Target 1: Transient Tachypnea of the Newborn (TTN)

• Transient tachypnea of the newborn (TTN) is a condition characterized by rapid breathing (tachypnea) in the first few hours after birth, typically caused by delayed clearance of fetal lung fluid. It often resolves within 24-48 hours.
• The newborn in the exhibit has a respiratory rate that is increasing: at 64 minutes, the rate is 68/min, and it increases to 76/min by 0700. This is significantly higher than the normal respiratory rate for a newborn (30-60/min) and is a key sign of tachypnea.
• Given the increased respiratory rate and the newborn’s age, transient tachypnea of the newborn is a likely concern. This condition is particularly common in late preterm and full-term infants who experience some delay in clearing fetal lung fluid after birth.

Target 2: Hypoglycemia

• Hypoglycemia in newborns can occur due to several factors, such as increased metabolic demand (which could be indicated by the tachycardia and respiratory rate), poor feeding, or stress during delivery.
• Tachycardia is one of the early signs of hypoglycemia in newborns, as the body responds to low blood sugar by increasing the heart rate to compensate for the lack of energy.
• The heart rate is consistently high, with values of 154/min and 156/min during the assessment. This tachycardia could be indicative of hypoglycemia, as the body works harder to compensate for low glucose levels.

Rationale for other conditions;

Bronchopulmonary Syndrome:

This condition refers to lung diseases like bronchopulmonary dysplasia (BPD), which typically occurs in premature infants who have had prolonged mechanical ventilation. There are no signs of this condition in the current assessment, such as the need for respiratory support or signs of chronic lung disease.

The newborn's respiratory rate and tachycardia are more consistent with transient tachypnea rather than a chronic condition like bronchopulmonary syndrome.

Tachycardia:

Tachycardia itself is a symptom, not a diagnosis. The infant's tachycardia could be a response to hypoxia or hypoglycemia, so the condition causing the tachycardia needs to be addressed (which is hypoglycemia and transient tachypnea of the newborn).