The nurse is assisting in caring for the client immediately after ...

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The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately?
 
  1. Stridor
  2. Lung congestion
  3. Respiratory rate of 26 breaths/min
  4. Occasional pink-tinged sputum

Question 2

The nurse is performing an assessment on a neonate. The nurse is preparing to measure the head circumference of the neonate. The nurse would:
 
  1. Wrap the paper tape around the newborn's head, and measure just above the eye-brows.
  2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes.
  3. Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth.
  4. Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.

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Answer to Question 1

1

Rationale: The nurse reports the presence of stridor to the physician immediately. This is a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. Congestion (lung congestion) and a respiratory rate of 26 breaths/min (respiratory rate of 26 breaths/min) are abnormal, but additional data are needed to determine whether these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

Answer to Question 2

2

Rationale: To measure head circumference, the nurse should place the paper tape under the newborn's head and wrap the tape around the newborn's head, measuring just above the eye-brows so that the largest area of the occiput is included.