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?

The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella.
How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

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

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

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?

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?

A nurse is caring for a client diagnosed with acute rhinosinusitis.

Which of the following instructions should the nurse provide to the client? Select all that apply. 

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?

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