The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse anticipate?

The client is awake and alert, interacting with parents at the bedside.
She has thin, copious mucus from her nose and mouth and a cough.
She took her bottle in 20 minutes, with no issues.
The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic.
The client was placed in a knee-to-chest position, and the rapid response team was called.
What could be the potential cause of the client’s condition?

A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?

The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

A newborn’s assessment reveals spina bifida occulta.
Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry.
Based on these findings, which action should the nurse implement?

A 3-year-old female patient woke up this morning feeling agitated and with a fever of 103.4° F (39.7° C). She was crying yesterday and reported back pain.

She has a history of asthma controlled by daily cetirizine and occasional albuterol.

She has had two urinary tract infections (UTIs) in the past 4 months.

Given the patient’s history and current condition, which condition is she most likely experiencing, what actions should the nurse take, and what parameters should the nurse monitor?

The nurse is educating parents on how to prevent recurrent otitis media in their infant.
What advice should the nurse give?

What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered.

The child lives with 2 older, school-age siblings, his parents, and 3 dogs.

He was born at 37 weeks’ gestation.

The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house.

He has no significant medical history.

He has received all vaccines except for those due at 3 years.

Upon exam, the child is… Which two items must the nurse ensure are available before attempting to place the intravenous line?