A nurse is caring for a newborn.

Vital Signs.

0640:. Temperature 36.7°C (98.1° F) axillary.

Heart rate 154/min.

Respiratory rate 68/min.

BP 72/48 mm Hg. 0650:. Heart rate 156/min.

Respiratory rate 72/min.

0700:. Temperature 37° C (98.6° F) axillary.

Heart rate 156/min.

Respiratory rate 76/min.

Admission Assessment.

0630:. Newborn delivered via cesarean birth under spinal anesthesia at. 0630.

Amniotic fluid clear.

0631:. 1-min Apgar score 7. 0636:. 5-min Apgar score 9. Newborn transferred to nursery.

Nurses' Notes.

0640:. Weight 4200 gm (9 Ib 4 oz), head circumference 35.5 cm (14 in). Respiratory rate 68/min, with mild grunting.

0650:. Respiratory rate 72/min, with mild grunting.

0700:. Respiratory rate 76/min, with moderate grunting and mild.

intercostal retractions.

Drag words from the choices below to fill in each blank in the following.

sentence.

The client is at risk for developing Target 1 and Target 2.

Choice A rationale:

Belching is a common finding following an esophagogastroduodenoscopy and is not a cause for concern unless it is excessive or accompanied by other concerning symptoms.

Choice B rationale:

(Correct Choice) Abdominal pain after an esophagogastroduodenoscopy can indicate complications such as perforation, bleeding, or infection. It is essential to report this finding to the provider promptly for further evaluation and management.

Choice C rationale:

Sore throat is a common and expected side effect after the procedure due to irritation from the endoscope. It usually resolves on its own and does not require immediate reporting unless it worsens or is associated with other concerning symptoms.

Choice D rationale:

Flatulence is not typically related to an esophagogastroduodenoscopy and is not a cause for concern in this context.

A) "My child has some swelling around her eyelids and mouth."

In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.

The other findings, while important, are not as immediately concerning:

B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.

C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.

D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.