A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

The client is at risk for developing transient tachypnea of the newborn andhypoglycemia.

Rationale

Target 1: Transient Tachypnea of the Newborn (TTN)

• Transient tachypnea of the newborn (TTN) is a condition characterized by rapid breathing (tachypnea) in the first few hours after birth, typically caused by delayed clearance of fetal lung fluid. It often resolves within 24-48 hours.
• The newborn in the exhibit has a respiratory rate that is increasing: at 64 minutes, the rate is 68/min, and it increases to 76/min by 0700. This is significantly higher than the normal respiratory rate for a newborn (30-60/min) and is a key sign of tachypnea.
• Given the increased respiratory rate and the newborn’s age, transient tachypnea of the newborn is a likely concern. This condition is particularly common in late preterm and full-term infants who experience some delay in clearing fetal lung fluid after birth.

Target 2: Hypoglycemia

• Hypoglycemia in newborns can occur due to several factors, such as increased metabolic demand (which could be indicated by the tachycardia and respiratory rate), poor feeding, or stress during delivery.
• Tachycardia is one of the early signs of hypoglycemia in newborns, as the body responds to low blood sugar by increasing the heart rate to compensate for the lack of energy.
• The heart rate is consistently high, with values of 154/min and 156/min during the assessment. This tachycardia could be indicative of hypoglycemia, as the body works harder to compensate for low glucose levels.

Rationale for other conditions;

Bronchopulmonary Syndrome:

This condition refers to lung diseases like bronchopulmonary dysplasia (BPD), which typically occurs in premature infants who have had prolonged mechanical ventilation. There are no signs of this condition in the current assessment, such as the need for respiratory support or signs of chronic lung disease.

The newborn's respiratory rate and tachycardia are more consistent with transient tachypnea rather than a chronic condition like bronchopulmonary syndrome.

Tachycardia:

Tachycardia itself is a symptom, not a diagnosis. The infant's tachycardia could be a response to hypoxia or hypoglycemia, so the condition causing the tachycardia needs to be addressed (which is hypoglycemia and transient tachypnea of the newborn).

Findings Requiring Immediate Follow-Up:

B. Hemoglobin and Hematocrit:
The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly lower than normal (14-18 g/dL for hemoglobin and 40-52% for hematocrit). This is indicative of anemia, which could be due to chronic blood loss, potentially from a gastrointestinal source (given the history of dark, tarry stool). Anemia can lead to symptoms such as weakness, dizziness, and fatigue, and if severe, it could lead to hypovolemic shock.
C. Stool results:
The hemoccult stool test is positive, indicating gastrointestinal bleeding, likely from an upper GI source (e.g., ulcers or gastritis). Combined with the client's symptoms of gnawing abdominal pain, a burning sensation radiating to the back, and a history of dark, tarry stools (which suggests melena), this is concerning for a peptic ulcer disease (PUD) or even a gastric ulcer. This finding warrants immediate follow-up to evaluate the cause and assess for complications such as active bleeding or perforation.
E. Blood Pressure:
The client’s blood pressure is 90/50 mm Hg, which is hypotensive and likely a sign of hypovolemia due to blood loss (from the GI bleeding indicated by the positive hemoccult test). Hypotension is a concerning finding, especially in a client with anemia and symptoms of abdominal distress. Immediate intervention is needed to address the blood pressure and prevent further complications, such as shock.
F. Temperature:
The client’s temperature is 37.5°C (99.5°F), which is slightly elevated (normal is typically 36.1-37.2°C or 97°F-99°F). While not dramatically high, a low-grade fever could suggest an infection (e.g., due to H. pylori, which is positive in this client, or an associated gastric infection or inflammation). In this case, it could indicate a need for monitoring, as infections can exacerbate symptoms and complications, particularly in the setting of a GI ulcer or bleeding.
H. Heart Rate:
The client's heart rate is elevated at 118 beats per minute (tachycardia). Tachycardia in this setting could be a compensatory mechanism for hypovolemia due to the blood loss suggested by the low hemoglobin/hematocrit and positive stool test. The elevated heart rate could also be a sign of pain, anxiety, or systemic response to the GI distress. Regardless, tachycardia is a significant finding in the context of hypotension and anemia and requires immediate follow-up to prevent cardiovascular complications.

Findings That Do Not Require Immediate Follow-Up:
A. Current Medications:
The client is taking Ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID). While NSAIDs can cause gastrointestinal irritation and increase the risk of bleeding (particularly in the presence of ulcers), the client’s current medications do not require immediate follow-up as a standalone issue. However, if a diagnosis of ulcer or gastrointestinal bleeding is confirmed, the use of NSAIDs should be discontinued.
D. WBC Count:
The client's WBC count is 6,700/mm³, which is within the normal range (5,000-10,000/mm³). This does not indicate infection or significant inflammation. Given the context of the client’s symptoms and lab results, there is no immediate concern with the WBC count at this time.
G. Respiratory Rate:
The client’s respiratory rate is 18/min, which is within the normal range (12-20 breaths per minute for adults). There is no indication of respiratory distress or abnormal breathing patterns in this patient, so no immediate follow-up is required in this area.