A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home. The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Choice A rationale Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing. Choice B rationale While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant. Choice C rationale Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing. Choice D rationale Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.