Patient Data Exhibits The nurse is prioritizing care for the client. Select the 3 highest priority findings for the nurse to address.
Explanation & Rationale
Rationale: A. Temperature: Mild fever (99.1°F/37.2°C) is present but has decreased from earlier measurements after acetaminophen administration. While it requires monitoring, it is not the most immediate priority compared with feeding and airway concerns. B. Refusing bottle: Feeding refusal places the infant at high risk for dehydration and inadequate nutrition, especially in the presence of a submucous cleft palate. This requires prompt intervention to maintain hydration and caloric intake. C. Signs of pain: Moderate pain is being managed with acetaminophen and sucrose, making it less urgent than airway and feeding issues at this time. D. Cough during feeding: This suggests possible aspiration risk, especially in the context of a submucous cleft palate. It may lead to respiratory complications and requires immediate evaluation. E. Oxygen saturation: Oxygen desaturation to 91% during feeding indicates potential airway compromise or aspiration, which requires immediate attention to prevent hypoxia. F. Formula coming from nares: This is a classic symptom of a cleft palate and provides important diagnostic information. While it is a significant finding, it is not an acute, life-threatening problem that requires immediate nursing action.