What nursing action is appropriate to take when an infant with a congenital heart defect has increased respiratory rate, is sweating, and is not feeding well?

Which type of respiratory condition is always considered an emergency?

Phase 1

A 5 year old is brought to her pediatrician for an annual routine checkup. Her grandparents, who are also the legal guardians, are with her. The child has not seen her pediatrician in a year. The child recently had a visit to the urgent care center and was treated for strep throat. The grandparents are concerned about the child’s weight gain. They state no matter how much she eats she cannot gain weight and is hungry all of the time. 

Phase 2

The primary care office does not have a glucometer available, so the provider orders a urinalysis dip stick test. The urinalysis shows a glucose of over 500mg/dl with blood, leukocytes, and ketones.  The results are shared with the grandparents along with the potential diagnosis and complications. The child’s grandparents are visibly upset and start asking the nurse questions about their grandchild.

Place each nursing action for the infant’s care during hospitalization into one of the 3 categories: indicated (appropriate or necessary), contraindicated (could be harmful), or non-essential (makes no difference or not necessary)

Which intervention should be included in the plan of care for an infant with the nursing diagnosis Fluid Volume Excess related to congestive heart failure?

The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. What is the nurse’s primary rationale for this action?

Phase 2:

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

Which nursing actions (interventions) are indicated for infant’s care at this time? (select all that apply)

Phase 1

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

Select and highlight the assessment findings that require follow up.

Phase 1

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

Medical History

Up to date with vaccine

No known allergies

Born at 39 weeks

Which congenital heart disease causes cyanosis when not repaired? (select all that apply)

Children with a history of Respiratory syncytial virus (RSV) infection are at an increase risk of developing asthma later in life.

Phase 1

A 5 year old is brought to her pediatrician for an annual routine checkup. Her grandparents, who are also the legal guardians, are with her. The child has not seen her pediatrician in a year. The child recently had a visit to the urgent care center and was treated for strep throat. The grandparents are concerned about the child’s weight gain. They state no matter how much she eats she cannot gain weight and is hungry all of the time. 

Highlight the conditions requiring immediate follow-up in the “follow-up” category.

Assessment:

Weight:15.9 kg

Height: 41 in

Heart rate: 122 beats per minute

Blood pressure: 96/44

Child is anxious, looks thin, and has dry lips and dry mucous membranes. Upon neck palpation the child has several enlarged cervical lymph nodes and has a “sweet odor to her breath, The remainder of the examination is within normal limits.

A pediatric client is admitted to the hospital unconscious. The client has a history of type 1 diabetes, and according to the clients mother, has been to two birthday parties in the last few days and has resisted taking the prescribed insulin. At school the client had two more pieces of birthday cake and some ice cream at a class birthday party. What is the likely reason for this client's unconscious state?