Nurses’ Notes Day 1, 1530:The 14-year-old transferred from the postanesthesia care unit following ORIF of left open femur fracture. Drowsy but arouses easily. Oriented to time, place and person. Peripheral IV in right hand with 0.9% sodium chloride 125 mL/hr. Surgical dressing intact on left thigh; small amount of serosanguinous drainage on distal aspect of dressing. Left foot is warm to touch, capillary refill is brisk, pedal pulse is 2+, sensation is intact and is able to wiggle toes upon command. Non-pitting edema of left toes and foot present. Adolescent reports headache pain as 3 and left leg pain as 4 on a of 0 to 10. Numerous abrasions are noted on face, upper and lower extremities and left hip area. Large bruise and tenderness noted in left flank area. 1730:Surgical dressing intact; moderate amount of serosanguinous drainage on distal aspect of dressing. Left foot is warm to touch, capillary refill is brisk, pedal pulse is 2+, sensation is intact and slowly wiggles toes upon command. Non-pitting edema of left toes and foot present. Adolescent reports headache pain as 9 and left leg pain as 8 on a scale of 0 to 10. Client is lethargic. Arouses briefly to tactile stimuli, is irritable and then quickly returns to sleep. PERRLA, hand grasps are equal and strong bilaterally. Abdomen is soft; nondistended with generalized tenderness upon palpation, bowel sounds are present in all four quadrants. Vital Signs Day 1, 1530:Temperature 36.3° C (97.3° F) Pulse rate 100/min Respiratory rate 18/min Blood pressure 108/70 mm Hg Oxygen saturation 97% on room air 1730:Temperature 37.2° C (98.9° F)Pulse rate 124/minRespiratory rate 16/minBlood pressure 96/66 mmHgOxygen saturation 96% on room air The nurse notifies the client’s healthcare provider about his change in condition. For each potential provider order, specify if the provider order is expected or unexpected.   Place on seizure precautions CT scan STAT Insert an indwelling urinary catheter Perform next neurological assessment in 8 hours. Place the client NPO

Complete the following sentence by choosing from the list of options. The client is most likely experiencing as most evidenced by .

Which of the following information from the newborn’s medical record indicates an increased risk for newborn complications? (Select all that apply).

A nurse is assessing a 9-month-old infant. Which finding should the nurse report to the provider?

The nurse is assessing primitive reflexes in a newborn. Which response indicates a normal Moro reflex?

Which findings require immediate follow up? (Select all that apply).

A nurse is providing discharge teaching to the parents of an infant who recently had a ventriculoperitoneal (VP) shunt placed. Which of the following statements indicate a need for further teaching? (Select all that apply).

A nurse is caring for an infant who has gastroesophageal reflux disease. The nurse should recognize that which of the following findings are associated with this condition? (Select all that apply.)

A nurse is educating a parent on preventing dehydration in a child with a fever and mild respiratory symptoms. Which instruction should the nurse prioritize to ensure effective hydration management at home?

A nurse is assessing a newborn 30 minutes after birth. Which finding is expected?