A nurse is caring for a client at 28 weeks of gestation who has a blood pressure reading of 162/108 mm Hg, and 4 hours previously it was 148/98 mm Hg. Which of the following orders should the nurse anticipate receiving? (Select all that apply))

Choice A rationale:

The temperature of 36.7°C (98.1°F) is within the normal range for newborns (36.5-37.5°C). Therefore, it does not require immediate follow-up.

Choice B rationale:

The respiratory rate of 74/min exceeds the normal range for newborns (30-60 breaths/min), indicating potential respiratory distress. Immediate follow-up is crucial to prevent respiratory failure.

Choice C rationale:

The heart rate of 170/min is above the normal range for newborns (120-160 beats/min). Tachycardia can indicate stress, infection, or other underlying conditions that need prompt evaluation.

Choice D rationale:

Work of breathing includes signs such as retractions, nasal flaring, and grunting, which indicate respiratory distress. These signs require immediate follow-up to address any potential respiratory complications.

Choice E

rationale: Blood glucose level is not mentioned in the question or exhibits. Without information on blood glucose, it is not possible to determine if it requires immediate follow-up.

Choice A rationale

Explaining that the newborn is no longer in pain may not facilitate grieving, as it does not acknowledge the emotional connection and grief the parents are experiencing.

Choice B rationale

Sharing the nurse's own experiences and feelings may shift the focus away from the client's emotions, potentially hindering their grieving process.

Choice C rationale

Avoiding calling the newborn by their name can create a sense of detachment and may prevent the client from fully processing their grief.

Choice D rationale

Allowing the client to hold or be with their newborn provides a tangible connection, facilitating the grieving process and helping them come to terms with their loss.