The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)

This is the most important complication for the practical nurse (PN) to anticipate because it is a common and potentially life-threatening condition that can occur in clients with severe burns. Curling's ulcer, also known as stress ulcer, is a type of peptic ulcer that develops in the stomach or duodenum as a result of stress, shock, trauma, or burns. It is caused by decreased blood flow and increased acid secretion in the gastrointestinal tract, which damages the mucosal lining and leads to ulceration and bleeding.

The PN should anticipate Curling's ulcer in a client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago, as this is a major risk factor for developing stress ulcers. The PN should monitor the client for signs and symptoms of Curling's ulcer, such as abdominal pain, nausea, vomiting, hematemesis, melena, and anemia. The PN should also administer prophylactic medications such as antacids, histamine-2 blockers, or proton pump inhibitors as prescribed by the health care provider.

The correct answer is C.

Choice A reason:

Repeating the heel stick for glucose in one hour is not the best first action because it delays necessary treatment and the infant's glucose could drop further, potentially causing harm.

Choice B reason:

Offering nipple feedings of 10% dextrose is not the initial treatment of choice for neonatal hypoglycemia. Oral dextrose gel may be used, but the priority is to provide a source of nutrition, such as breast milk or formula, which offers more sustained glucose levels.

Choice C reason:

Begin frequent feedings of breast milk or formula. This is the first intervention to implement because the infant's current glucose level is below the normal neonatal range of [30 to 60 mg/dL or 1.7 to 3.3 mmol/L], indicating hypoglycemia, which is common in infants of mothers with gestational diabetes. Immediate feeding can help raise the blood glucose level safely.

Choice D reason:

Assessing for signs of hypocalcemia is not the immediate priority. While hypocalcemia can occur in newborns, particularly those with maternal diabetes, the current symptoms and glucose level suggest hypoglycemia is the primary concern. Signs of hypocalcemia include irritability, muscle twitches, jitteriness, tremors, and poor feeding, which can overlap with hypoglycemia symptoms. However, the heel stick glucose level clearly indicates hypoglycemia, which should be addressed first.