SOLVED4503

Client noted to have increased work of breathing, scattered crackles in bilateral lower lobes, moderate intercostal and substernal retractions. Skin color is pink throughout. S1 and S2 heart sounds, holosystolic murmur present, regular rhythm. 1+ pedal edema. 2+ pulses in all four extremities. Capillary refill time 3 seconds. Mom reports client had one soft, formed stool this morning. Client has taken 2 ounces of 24-calorie formula at 0800 and 1100. No spitting up or vomiting. Weight 4.8 kg (10 lb 8 oz). Temp 98.4°F (36.8°C), HR 155 bpm, RR 65 breaths/min, SpO2 94% on room air, BP 80/62 mm Hg
SCIENCE
HEALTH SCIENCE
NURSING

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