A nurse on a medical unit is admitting a client.

Exhibits

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Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

Choice A Rationale: Puncturing the heel to a depth of 4 mm may be too deep and could cause injury to the newborn's foot. The recommended depth is usually less than 2 mm to avoid damaging underlying bone or tissues.
Choice B Rationale: Withholding feeding prior to collecting the specimen is not necessary and could cause unnecessary distress to the newborn. Feeding can help in soothing the infant and may even improve blood flow for the procedure.
Choice C Rationale: Applying a heat pack 5 to 10 minutes prior to the procedure is recommended as it helps to increase blood flow to the area, making the collection easier and potentially less painful for the newborn.
Choice D Rationale: Elevating the newborn's foot for 15 minutes following the procedure is not a standard recommendation. Post-procedure care typically involves applying gentle pressure to stop bleeding and then covering the puncture site with a bandage.

A. Switch to a soy-based formula: Bloody stools in infants can be indicative of a cow's milk protein allergy or intolerance. Switching to a soy-based formula may alleviate symptoms in such cases.
B. Switch to a goat's milk formula: Goat's milk is not recommended for infants as it lacks essential nutrients and can lead to nutritional deficiencies and other health issues.
C. Switch to an unpasteurized milk formula: Unpasteurized milk poses a risk of bacterial contamination and is not recommended, especially for infants who are more susceptible to infections.
D. Switch to a condensed milk formula: Condensed milk is not suitable as a primary source of nutrition for infants and does not address the potential underlying issue of cow's milk intolerance.