The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

A. being cold: Being cold is not directly related to the symptoms described in the scenario.

The client's symptoms include dizziness, headache, burning feeling on extremities, and redness on face and extremities, but there is no mention of feeling cold.
B. dyspnea: Dyspnea, or difficulty breathing, may occur as a result of an adverse reaction such as anaphylaxis or severe cardiovascular compromise. It is a concerning symptom that warrants immediate attention and intervention.

C. shaking: Shaking is not mentioned in the client's symptoms in the scenario. While it can be a sign of distress or discomfort, it is not directly related to the symptoms of dyspnea, nausea, and headache described.
D. nausea: Nausea is a common symptom associated with adverse reactions to medications, including allergic reactions or cardiovascular events. It can contribute to the client's overall discomfort and may indicate ongoing or worsening adverse effects.
E. blood pressure 116/68 mm Hg: The client's blood pressure of 116/68 mm Hg is not

indicative of ongoing adverse reactions. While the initial blood pressure reading was low (108/46 mm Hg), it is not included as part of the ongoing symptoms described.
F. headache: Headache can be a manifestation of various adverse reactions, including allergic reactions or changes in blood pressure. It is a symptom that should be monitored closely as it can indicate ongoing or worsening complications.

Hypocalcemia:

- Condition: Hypocalcemia is a condition characterized by low levels of calcium in the blood. In newborns and infants, this can occur due to inadequate intake or absorption of calcium, and it can manifest as seizures.

- Rationale: The infant was fed cow's milk, which is not recommended for infants under one year old and can interfere with calcium absorption, possibly leading to hypocalcemia. Seizures can be a symptom of severe hypocalcemia.

Actions to Take:

1. Administer oral calcium:

- Rationale: Direct administration of calcium helps to quickly elevate calcium levels in the blood, addressing the immediate cause of the seizures.
2. Educate the mother on nutrition needs:

- Rationale: It's important to educate the mother on the appropriate nutritional needs for an

infant, emphasizing the importance of breastfeeding or formula feeding instead of cow's milk, to prevent recurrence.

Parameters to Monitor:

1. Electrocardiogram:

- Rationale: Monitoring the ECG is crucial as hypocalcemia can cause cardiac arrhythmias, and the ECG can provide real-time information about the infant's cardiac status.
2. Oxygen saturation:

- Rationale: Monitoring oxygen saturation ensures that the infant maintains adequate oxygenation, especially after a seizure and during recovery, to detect any respiratory complications early.