The nurse is caring for a client.

Which of the following 4 orders or prescriptions should the nurse anticipate?
Select the 4 orders or prescriptions that the nurse should anticipate.

A. Apply a cool cloth to the infant's heel 5 min prior to the procedure: Cooling the skin can cause vasoconstriction, making the heel stick more difficult and potentially increasing discomfort. This intervention does not support pain reduction and may prolong the procedure, which can further distress the infant.

B. Promote skin-to-skin contact with the infant's guardian during the procedure: Skin-to-skin contact is an evidence-based method that reduces procedural pain in infants by stabilizing heart rate, enhancing comfort, and lowering stress responses. It offers both analgesic and calming effects, making it an effective strategy during heel sticks.

C. Provide the infant with a bottle of water during the procedure: Water does not provide analgesic benefit to infants and does not activate soothing mechanisms such as the sucrose-induced endorphin release used for pain relief. Offering plain water may also be inappropriate for young infants due to risk of water intoxication.

D. Apply lidocaine/prilocaine cream 15 min prior to the procedure: This topical anesthetic requires significantly longer, typically 30 to 60 minutes, to achieve adequate analgesic effect. Applying it only 15 minutes before the heel stick would not provide sufficient pain control, limiting its effectiveness.

A. Orientation: The client is alert only to name and not fully oriented, indicating acute neurological changes. This requires immediate follow-up to assess for possible stroke or other neurological compromise.

B. Breath sounds: Breath sounds are vesicular and bronchovesicular with full thoracic excursion, which is within normal limits. No follow-up is immediately required.

C. Gag reflex: The absence of a gag reflex is a significant finding, increasing the risk of aspiration and airway compromise. Immediate assessment and interventions are necessary to protect the airway.

D. Pupils: Pupils are equal and reactive bilaterally, which is within normal limits. No follow-up is required for this finding.

E. Extremity circulation: Pulses are +2 with capillary refill less than 2 seconds in all extremities, indicating adequate perfusion. No follow-up is needed at this time.

F. Speech: The client’s speech is unintelligible, indicating acute neurological compromise. This requires urgent follow-up and possible intervention for stroke or transient ischemic attack.

G. Grip strength: Decreased grip strength in the right upper extremity indicates motor deficits consistent with neurological injury, requiring immediate assessment and intervention.

H. Thoracic findings: Full and symmetric thoracic excursion with normal breath sounds is within normal limits, requiring no follow-up.

I. Heart sounds: S1 and S2 are present, and the cardiac monitor shows sinus tachycardia without additional abnormalities, which does not require immediate follow-up.