The nurse is assessing a client with pneumonia who has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears adventitious sounds in the lower left lobe. The client’s oxygen saturation is 72%. Which action should the nurse take first?
Read DetailsA student nurse is completing a careplan for an immobilized bed-bound client. The student has included a 2-hour turning and positioning program in planning/implementation. How does the student nurse explain the importance of this turning/positioning for the client?
Read DetailsYou are called to an emergent cesarean section of a full term neonate due to non-reassuring fetal heart rate tracings. Mother was noted to have a uterine rupture. Apgars were 0 at 1 minute of life, 3 at 5 minutes of life, and 4 at 10 minutes of life. The neonate required a full resuscitation following birth including intubation/ventilation, chest compressions, two 10 ml/kg normal saline boluses, and several doses of epinephrine. The neonate has an abnormal neurological exam compatible with severe hypoxic ischemic encephalopathy and has been having seizures. At 24 hours of age, the Na+ level is 128, the creatinine is 1.6, and the urine output is 0.5 ml/kg/hr. Which of the following actions are appropriate?
Read DetailsYou are called emergently to a Cesarean section for a maternal abruption. The infant is flaccid, cyanotic, has no reflex response with drying/stimulation, and no cry. There is some irregular chest movement. Upon auscultation, the heart rate is 80. What APGAR would you assign this infant?
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