In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Reference Range:

Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]

Acute kidney injury (AKI) can have significant impacts on the client's fluid and electrolyte balance. Mannitol, a diuretic, is commonly used to promote diuresis and increase urine

output in cases of AKI. However, it is essential to assess the client's hemodynamic status and overall condition before administering mannitol.

Obtaining vital signs (such as blood pressure, heart rate, respiratory rate, and temperature) helps evaluate the client's baseline status and monitor for any changes that may occur after administering mannitol. It is particularly important to assess blood pressure as mannitol can potentially cause hypotension as a side effect.

Assessing breath sounds is also crucial because pulmonary edema can occur as a complication of AKI. Mannitol administration may exacerbate this condition. Therefore, assessing breath sounds allows the nurse to monitor for signs of fluid overload, such as crackles or wheezes.

Collecting a clean catch urine specimen may be necessary for diagnostic purposes to assess kidney function and determine the presence or severity of acute kidney injury. However, obtaining vital signs and assessing breath sounds should be the first nursing intervention before administering any medication, including mannitol, to ensure the client's safety and monitor for any potential adverse effects.

It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.

Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.

Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.

It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.

Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.

Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.