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
A fetal heart rate (FHR) of 110 beats per minute with moderate variability and accelerations is within the normal range (110-160 bpm). Moderate variability indicates a healthy, well-oxygenated fetus, and accelerations are reassuring signs. This client is stable and does not require immediate intervention.
Choice B rationale
A client with an epidural who is 7 cm dilated is stable. The nurse should continue to monitor the client's progress and vital signs, but there is no indication of immediate distress. The epidural can cause a slight decrease in blood pressure, which would require monitoring but not an urgent response.
Choice C rationale
A blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98% are all within normal ranges. This client is stable and does not have any signs of distress. The nurse should continue to monitor the client but does not need to see them first.
Choice D rationale
A fetal heart rate baseline of 130s is normal, but minimal variability and late decelerations are non-reassuring signs. Minimal variability (less than 6 beats per minute) indicates a potential lack of fetal oxygenation, while late decelerations are a sign of uteroplacental insufficiency. This requires immediate intervention.
Correct Answer is D
Explanation
Choice A rationale
While positioning the client is a crucial step for the procedure, it is not the first priority. The client is positioned after the preliminary steps, such as administering the fluid bolus, are completed. The fetal position is used to open the intervertebral spaces, allowing for easier needle insertion. However, the first priority is to prevent a known and common complication.
Choice B rationale
Preparing a sterile field is a necessary step for any invasive procedure to prevent infection. The supplies are prepared while the client is getting ready for the procedure. However, the priority intervention is focused on the client's physiological safety and preventing a known and common complication, which takes precedence over setting up the sterile field.
Choice C rationale
Reviewing the client's medical history and lab results is part of the initial admission process and is necessary to ensure the client is a suitable candidate for the procedure. This is done before the decision is made to proceed with the epidural. However, the priority intervention immediately before the procedure is a physiological intervention to prevent a potential complication.
Choice D rationale
Epidural anesthesia can cause vasodilation and a rapid drop in blood pressure due to the blockade of sympathetic nerves. A fluid bolus, typically 500-1000 mL of an isotonic solution, is administered to increase intravascular volume and preload, which helps to counteract this potential hypotensive effect. Preventing maternal hypotension is a priority because it can lead to decreased placental perfusion and fetal distress.
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