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?

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

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 woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit.
The nurse knows that assessment for which complication is the highest priority for this client?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.
What action should the nurse take?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. After reading the history and physical, the nurse suspects the child has

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis.
What action should the nurse take?

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