A 2-year-old toddler is seen for croup (acute laryngotracheobronchitis). What observation would lead the nurse to suspect airway occlusion?
The nasal discharge is increasing.
The cough is becoming harsher.
The respiratory rate is gradually increasing.
The toddler states being tired and wanting to sleep.
The Correct Answer is D
Choice A rationale
Increasing nasal discharge is a common symptom of upper respiratory tract infections and does not specifically indicate a progression to airway occlusion in croup. While it contributes to overall respiratory distress, it is not the most critical sign of a life-threatening compromise of the airway in this condition.
Choice B rationale
A harsher cough, often described as a "barking" cough, is a characteristic symptom of croup caused by inflammation of the larynx, trachea, and bronchi. While concerning, it is not the most reliable indicator of impending airway occlusion. The cough may be present throughout the illness without a complete occlusion.
Choice C rationale
An increasing respiratory rate is an early compensatory mechanism in response to airway obstruction and hypoxia. While it indicates respiratory distress, it is not the most significant sign of impending airway occlusion. It can occur with many respiratory issues and is often a precursor to more severe signs.
Choice D rationale
A toddler stating they are tired and wanting to sleep is a serious and late sign of hypoxia. This indicates that the child is becoming fatigued from the increased work of breathing, leading to decreased respiratory effort. This mental status change signals that the body's compensatory mechanisms are failing, and respiratory failure and airway occlusion are imminent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Assessing for the need for pain medication is not appropriate at 10 cm dilation. At this stage, the client is in the second stage of labor, which is characterized by pushing and the birth of the baby. The use of pain medication at this point could potentially suppress the mother’s urge to push and prolong labor, so it is generally not a priority.
Choice B rationale
Administering oxytocin is not the correct action. Oxytocin is a hormone used to induce or augment labor. A client who has reached 10 cm dilation is in the second stage of labor and no longer needs augmentation. Administering oxytocin at this stage could increase the risk of uterine hyperstimulation and fetal distress.
Choice C rationale
The client's dinner is irrelevant at this stage of labor. A client at 10 cm dilation is in the second stage of labor, which is the pushing phase leading to birth. Oral intake is typically restricted during active labor to prevent the risk of aspiration if general anesthesia is required, and a meal is not a consideration.
Choice D rationale
When the client reaches 10 cm dilation, the cervix is fully dilated and effaced, signifying the end of the first stage of labor. This is the transition to the second stage of labor, which involves pushing and delivery. The nurse's next action is to prepare for this stage by setting up sterile equipment, positioning the client, and providing coaching for pushing efforts.
Correct Answer is D
Explanation
Choice A rationale
Rapid breathing games would worsen the child's condition. Rapid breathing, or hyperventilation, can lead to respiratory alkalosis, which is an imbalance in the body's acid-base balance. It can also cause dehydration and further irritate the respiratory tract, increasing the child's discomfort and potentially exacerbating the symptoms of the upper respiratory infection.
Choice B rationale
Enforcing strict bed rest is generally not necessary and can sometimes be detrimental. While rest is important, complete immobility can increase the risk of complications such as pneumonia due to a lack of lung expansion. Moderate activity is often encouraged to prevent pooling of secretions and to maintain normal respiratory function.
Choice C rationale
Limiting fluid intake is contraindicated. Adequate hydration is crucial for a child with an upper respiratory infection. Fluids help to thin respiratory secretions, making them easier to clear from the airways, and prevent dehydration, which can be a significant risk, especially if the child has a fever.
Choice D rationale
Increasing room humidity is a beneficial measure. Humidified air helps to soothe inflamed respiratory passages and moisten secretions, making them less viscous and easier for the child to cough up. This can significantly reduce nasal congestion, cough, and throat irritation, improving the child's ability to breathe comfortably.
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