The nurse notices that a 5-month-old infant in a CCU is having difficulty breathing, with nasal flaring, audible grunting, and sternal and intercostal retractions. The infant's respiratory rate is rapid, and the infant is restless and obtunded
What intervention should the nurse implement first?
A) Position the baby with head in a neutral midline position and apply the jaw-thrust maneuver.
B) Facilitate administration of an inhaled bronchodilator.
C) Administer intravenous sedation or pain medication.
D) Ask the parent to use comforting measures for the infant.
A
You might also like to view...
A pediatric nurse is caring for a 5-year-old female patient. When giving the child an injection preoperatively, the patient cries and states, "Now everything will leak out." The nurse knows that this is an example of what?
A) Impulsivity B) Fear C) Magical thinking D) Egocentrism
The nurse aspirates from the nasointestinal tube. Which requires the nurse to plan follow-up nursing interventions?
1. Aspirated liquid totals 5 ml of greenish fluid. 2. Feeding tube collapses with negative pressure. 3. Nurse aspirates a small amount of the formula. 4. Aspirated liquid appears pale and straw colored.
What is most likely the shape of the face of a child diagnosed with Russell-Silver syndrome?
a. Round b. Square c. Triangular d. Elongated
A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells a nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer's solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? Select all that apply.
A. Blood serum glucose B. Pulse rate and quality C. Urinary output D. Urine specific gravity levels