Nurse Essay

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Meet the Client: Grace Hicks Six-week-old Grace arrives in the emergency department by ambulance with her mother Wendy. The mother stated that the infant has had a 2-day history of cold symptoms. Today, the infant became limp, cyanotic, and was not breathing. The mother revived the infant by performing mouth-to-mouth resuscitation. An ambulance arrives and the emergency medical technician (EMT) stabilized Grace before transporting the infant to the Emergency Center. This information is reported to the nurse by the EMT upon the infant’s arrival to the Emergency Center. Assessment When the nurse enters the room she finds Grace crying in her mother's arms. The nurse and Wendy calm Grace, and then the nurse auscultates the infant's lungs. Coarse bilateral wheezes are detected, but the infant does not appear in acute distress at this time. 1. What action should the nurse take next? A) Perform nasal suctioning. INCORRECT Since the infant is not in distress, nasal suctioning is not necessary at this time. B) Continue respiratory assessment. CORRECT The nurse should complete the respiratory assessment, as this will provide important baseline information for the healthcare provider (HCP). C) Call the emergency response team. INCORRECT Since the infant is not in acute distress, calling the emergency response team is not necessary at this time. D) Document assessment findings. INCORRECT Although documenting the information the nurse assessed and the EMT provided, more assessment needs to be done first. Points Earned: 1.0/1.0 Correct Answer(s): B 2. What technique (s) should the nurse use to assess for respiratory distress? (Select all that apply.) A) Place a pulse oximeter on a big toe of the baby’s foot. CORRECT The nurse should use a pulse oximeter to measure the infant’s oxygen saturation level. A decreased

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