A nurse is conducting a pressure injury risk assessment on a client. Which of the following findings places the client at the highest risk for skin breakdown?

A. Increased thirst: This is typically a manifestation of hyperglycemia rather than hypoglycemia. Hyperglycemia can lead to dehydration due to the body’s attempt to flush out excess glucose through urine, which then causes increased thirst.
B. Urinary frequency: Urinary frequency is also a symptom commonly associated with hyperglycemia rather than hypoglycemia. When blood sugar levels are too high, the kidneys try to remove excess glucose, leading to frequent urination causing polyuria and is typically seen in hyperglycemic states, not in low blood sugar situations.
C. Weakness: Weakness is a classic symptom of hypoglycemia. When blood glucose levels drop too low, the body does not have enough fuel to function properly, leading to fatigue and weakness. This symptom is often experienced as one of the early signs of hypoglycemia and should be closely monitored in diabetic patients.
D. Skin flushing: Flushed skin is not a typical feature of hypoglycemia. Hypoglycemia more commonly causes cool, pale, and clammy skin due to sympathetic nervous system activation.

A. Avoid feeding the infant more than once every 3 hr: Newborns should be fed on demand, which typically occurs every 1-3 hours, but it can vary. Some babies may want to nurse more frequently, especially in the early days, for comfort or to stimulate milk production. Restricting feedings to a set time interval can hinder the infant's ability to receive enough nourishment.
B. Provide the newborn with 15 mL of sterile water each day: Breast milk or formula provides all the hydration and nutrition the infant needs. Offering water can interfere with the infant's intake of breast milk, which is essential for proper growth and development.
C. Store expressed milk in the refrigerator for up to 7 days: While expressed breast milk can be stored in the refrigerator, the recommended storage time is typically 3-5 days, not 7 days. Storing milk for longer periods may increase the risk of bacterial growth, which could compromise the milk's safety and quality.
D. Feedings should begin within 1 hour after birth: Initiating breastfeeding within the first hour after birth is critical for both mother and baby. Early initiation of breastfeeding helps establish a good milk supply, promotes bonding, and provides the newborn with colostrum, which is rich in antibodies and nutrients essential for the baby’s immune system and overall health.