A swollen joint.

The practical nurse (PN) is caring for a 20-month-old toddler who was admitted with a sickle cell crisis.

The mother rocks the toddler who continues to cry, is restless, and does not wish to be touched.

The electronic monitoring device indicates that the toddler's temperature is 102° F (38.8° C), heart rate is 140 beats/minute, blood pressure 122/70 mm Hg, and oxygen saturation 98%. Which problem(s) should the PN document as the priority in the client's plan of care (POC)? Select all that apply.

Choice A rationale

Giving prescribed digoxin and furosemide is part of the long-term management for cardiac conditions, but these medications do not provide immediate relief for an acute hypoxic spell. Digoxin improves cardiac contractility, and furosemide promotes fluid excretion, but their onset of action is not rapid enough for emergent situations.

Choice B rationale

Returning the child to bed and elevating the head of the bed might provide some comfort but does not directly address the underlying physiological cause of the hypoxic spell. Elevating the head of the bed may slightly improve respiratory effort but won't reverse cyanosis effectively.

Choice C rationale

Offering to play a board game with the child as a distraction does not address the physiological emergency of a hypoxic spell. Distraction may be helpful for anxiety but is not an intervention for cyanosis, tachypnea, and tachycardia, which require medical intervention.

Choice D rationale

Providing oxygen increases the available oxygen for gas exchange, and promoting the knee-chest position reduces venous return to the heart, thereby decreasing right-to-left shunting and improving pulmonary blood flow in conditions like Tetralogy of Fallot, which commonly presents with "squatting" and hypoxic spells.

Choice A rationale

Collecting a urine specimen for electrolytes and protein would provide data related to renal function and fluid balance, but it does not directly address the client's current subjective symptoms of restlessness and apprehension. These symptoms are more indicative of potential hypoxemia or a psychological response to stress, which requires a more immediate and direct assessment and intervention focused on maternal-fetal well-being rather than baseline lab work. Normal urine specific gravity is 1.005-1.030, and protein should be negative.

Choice B rationale

Moving the client into a dorsal recumbent position can actually compress the inferior vena cava, leading to supine hypotensive syndrome, which further compromises placental perfusion and exacerbates fetal distress. This position is contraindicated in laboring clients, particularly when signs of potential distress are present. The ideal position for laboring clients is typically left lateral, which optimizes uterine perfusion and oxygenation.

Choice C rationale

Encouraging the client to push with the next contraction is inappropriate given the client's symptoms of restlessness and apprehension, especially at 42 weeks gestation with chorioamnionitis. These symptoms could indicate evolving fetal distress or a change in maternal status requiring further assessment, not active pushing. Pushing without complete cervical dilation can lead to cervical edema or trauma.

Choice D rationale

Providing information about the baby's status can alleviate the client's anxiety and apprehension by addressing her immediate concerns about the well-being of her fetus. Restlessness and apprehension in a laboring client, particularly with a diagnosis of chorioamnionitis, can be a symptom of hypoxemia or other complications. Open communication and reassurance are crucial in managing maternal stress and promoting a sense of control.