A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?
Flaring of the nares.
Resting respiratory rate of 35 breaths/minute.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
The Correct Answer is A
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Scoliosis screening is typically performed on early adolescent girls, as this is the age group that is most commonly affected by the condition. Early detection and intervention can help prevent the progression of scoliosis and improve outcomes.
Correct Answer is B
Explanation
Based on the assessment findings, the infant is at the greatest risk for developing anemia due to a lack of iron. Infants should begin eating solid foods that are rich in iron at around 6 months of age to ensure they are getting enough of this important nutrient. Drinking whole milk from a bottle can displace other foods that are rich in iron and contribute to the development of anemia.
Option A, allergies related to whole milk, is a possibility but not the greatest risk in this situation.
Option C, obesity due to increased calorie count, is also a possibility but not the greatest risk.
Option D, lactose intolerance due to whole milk, is a possibility but not the greatest risk in this situation.

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