A client diagnosed with a PE is placed on a heparin drip. The nurse knows that she must monitor which of the following?

A. Placing infants on their backs or sides for sleep:The "Back to Sleep" campaign recommends placing infants on their backs for all sleep times to significantly reduce the risk of SIDS. Back sleeping it keeps the airway more open and reduces the chance of suffocation.

B. Positioning the infant prone for sleep:Placing an infant on their stomach increases the risk of SIDS due to potential airway obstruction and rebreathing of exhaled carbon dioxide. This position is strongly discouraged by pediatric guidelines for safe sleep.

C. Wrapping the infant snugly for rest periods:Swaddling can be safe if done correctly, but wrapping too tightly, especially around the chest or hips, and using loose blankets can increase the risk of overheating or suffocation.

D. Sitting the infant up in an infant seat:Keeping an infant in a sitting position for sleep, such as in a car seat or infant carrier, increases the risk of airway obstruction and is not recommended for routine sleep. Infants should sleep on a flat, firm surface to reduce the risk of SIDS.

A. Determining the last time the patient was suctioned:The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.

B. Auscultating the breath sounds:Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.

C. Monitoring the rate of respirations:An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.

D. Examining the character of the sputum:Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.