The nurse is assisting in planning care for a child.
Which of the following interventions should the nurse plan to include?

Choice A rationale: Steatorrhea during stool analysis, characterized by greasy, foul-smelling stools due to excess fat, is typically associated with malabsorption syndromes such as cystic fibrosis or chronic pancreatitis. While this warrants further evaluation, it is not directly linked to acute respiratory symptoms such as difficulty breathing or coughing up blood. Thus, this finding does not necessitate immediate intervention compared to the urgent risks posed by hemoptysis.

Choice B rationale: Barrel chest, often associated with chronic obstructive pulmonary disease (COPD), reflects long-term structural changes due to chronic air trapping. While it is an important finding requiring ongoing management, it is not an acute issue demanding urgent intervention. It does not directly explain symptoms like hemoptysis or respiratory distress, which indicate more critical underlying conditions requiring immediate attention.

Choice C rationale: An oxygen saturation of 95% on 1 L oxygen via nasal cannula is within the acceptable range for most individuals, with normal oxygen saturation values typically between 95% and 100%. This finding does not indicate severe hypoxemia or a deteriorating respiratory status. As such, it does not require urgent intervention compared to significant bleeding in the respiratory tract.

Choice D rationale: Hemoptysis of 300 mL is a critical finding requiring urgent intervention. This volume of blood indicates severe hemorrhage in the respiratory tract, which can compromise the airway, lead to hypovolemic shock, and cause respiratory failure if not addressed promptly. Immediate evaluation is necessary to identify the source of bleeding and initiate lifesaving treatments such as airway stabilization and hemorrhage control.

Choice A rationale: Increased weight-bearing ability on the affected leg is typically an expected finding, especially as the client begins to recover postoperatively. Enhanced weight-bearing suggests improving strength, mobility, and healing in the affected limb. It does not usually indicate complications. As such, this finding does not necessitate reporting unless accompanied by other concerning symptoms, such as significant pain or changes in circulation.

Choice B rationale: Warmth extending from the left calf to the knee could indicate localized inflammation or infection. However, warmth alone is not definitive for conditions like deep vein thrombosis (DVT) or cellulitis. Without additional findings such as swelling, redness, or pain, it may not be immediately concerning. Nevertheless, it warrants monitoring as a precaution, particularly in postsurgical clients at risk for complications like DVT.

Choice C rationale: A temperature of 38.8° C (101.8° F) is above the normal range of 36.1° C to 37.2° C (97.0° F to 99.0° F) and suggests the possibility of a systemic infection, such as a postoperative wound infection. This finding is significant and must be reported promptly to the healthcare provider for further evaluation and intervention. Early detection and treatment of infections are crucial to prevent complications like sepsis.

Choice D rationale: Itching in bilateral antecubital spaces is a nonspecific symptom that may be attributed to a mild allergic reaction, irritation, or dryness of the skin. While it could indicate a reaction to medications or adhesives used during surgery, it is generally not an urgent concern unless accompanied by additional symptoms like rash, swelling, or respiratory distress. Close monitoring is recommended rather than immediate reporting.