Final answer:
The most critical finding is an elevated heart rate of 150 beats per minute, which is a priority because it suggests compensatory tachycardia due to hypoperfusion. A patient with a blood pressure of 70/45 and confusion is likely in a state of hypovolemia and shock. Difficulty inflating the lungs is expected in premature babies lacking sufficient pulmonary surfactant.
Step-by-step explanation:
In response to the priority findings, the nurse should identify option C, HR 150 (heart rate of 150 beats per minute), as the priority. This elevated heart rate could signify compensatory tachycardia due to hypoperfusion and is a direct indicator of the body's response to a potential state of shock or severe dehydration.
A patient with a blood pressure of 70/45, confusion, and complaining of thirst is likely experiencing these symptoms due to hypovolemia, which can lead to shock and is potentially life-threatening. The confusion and thirst are indicative of inadequate cerebral perfusion and dehydration, respectively. The dangerously low blood pressure indicates that the patient's net filtration pressure would be altered, leading to poor tissue perfusion and organ function.
If a baby is born prematurely without sufficient pulmonary surfactant from type II cells, one might expect the baby to have difficulty inflating the lungs (option b) because surfactant reduces surface tension and allows the lungs to expand with less force.