The nurse on the pediatric unit is assigned to an infant with gastroesophageal reflux. The infant has had episodes of pneumonia and is not gaining weight
The infant has not responded well to 6 weeks of medical management and is being considered for surgery. At the beginning of the shift, after receiving report on this infant, the nurse will first: a. read the infant's chart or computer record
b. weigh the infant
c. assess respiratory status
d. check the medication administration record and set up medications
C
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A Incorrect. At the beginning of the shift, after receiving report on this infant, the nurse will not first read the infant's chart or computer record
B Incorrect. At the beginning of the shift, after receiving report on this infant, the nurse will not first weigh the infant.
C Correct. At the beginning of the shift, after receiving report on this infant, the nurse will first assess respiratory status. Infants with GER are at high risk for aspiration; therefore, assessment of a baseline respiratory status is imperative, such as lung sounds, respiratory rate, and effort. Additionally, this infant has previously had episodes of pneumonia.
D Incorrect. At the beginning of the shift, after receiving report on this infant, the nurse will not first check the medication administration record and set up medications.
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