The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery. Which infant should the PN assess first?

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.

This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment. The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.

A. Increased diaphoresis during the day and night is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.

B. Breast engorgement on the fourth postpartum day is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.

C. Lochia color that changes to light pink or white is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.