A 4-month-old has been admitted to the pediatric medical unit with respiratory syncytial virus (RSV). The infant demonstrates poor feeding and begins coughing frequently. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Flaring of the nares.

Diaphragmatic respirations.

Resting respiratory rate of 35 breaths/minute.

Bilateral bronchial breath sounds.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Flaring of the nares: Flaring of the nares occurs when the infant is working harder to breathe and indicates increased respiratory effort. In the context of RSV with poor feeding and frequent coughing, this is a key sign of respiratory distress that requires prompt attention.

B. Diaphragmatic respirations: Diaphragmatic (abdominal) breathing is normal in infants and reflects typical respiratory mechanics. It does not indicate respiratory distress unless accompanied by other abnormal signs like retractions or nasal flaring.

C. Resting respiratory rate of 35 breaths/minute: A respiratory rate of 35 is within the normal range for a 4-month-old (30–60 breaths/minute). Alone, it does not signify distress, though trends or additional signs should be monitored.

D. Bilateral bronchial breath sounds: Bilateral bronchial breath sounds can be normal over the central airways. This finding does not indicate respiratory distress and may reflect normal auscultatory findings in infants.

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Free Nursing Study Resources

Correct Answer is ["35"]

Explanation

Calculation:

Calculate the difference in weight between the wet and dry diaper.

Weight difference (grams) = Wet diaper weight (grams) - Dry diaper weight (grams)

= 85 grams - 50 grams

= 35 grams.

Convert the weight difference in grams to milliliters (mL).

Conversion factor: 1 gram = 1 mL

Urine output (mL) = Weight difference (grams) x 1 mL/gram

= 35 grams x 1 mL/gram

= 35 mL.

A. Return of the uterus to prepregnancy size. B. Expulsion of the placenta. C. Activation of the let down reflex. D. Stimulation of uterine contractions.

Correct Answer is D

Explanation

Rationale:

A. Return of the uterus to prepregnancy size: While oxytocin helps the uterus contract, uterine involution occurs gradually over several weeks and is not an immediate outcome of oxytocin administration.

B. Expulsion of the placenta: Oxytocin is sometimes used to prevent postpartum hemorrhage after placental delivery, but the actual expulsion of the placenta occurs before oxytocin is routinely administered.

C. Activation of the let-down reflex: The let-down reflex, which triggers milk ejection, is stimulated by oxytocin during breastfeeding. However, in the postpartum IV setting, the primary purpose of oxytocin is uterine contraction, not lactation.

D. Stimulation of uterine contractions: Oxytocin directly stimulates smooth muscle of the uterus, promoting strong contractions. This helps control postpartum bleeding and supports the uterus in returning to a contracted state, which is the expected outcome after delivery.

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A 4-month-old has been admitted to the pediatric medical unit with respiratory syncytial virus (RSV). The infant demonstrates poor feeding and begins coughing frequently. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How many mL of urine output should the nurse document for an infant's wet diaper weight of 85 grams compared to the dry diaper weight of 50 grams? (Enter numeric value only.)

Correct Answer is ["35"]

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse is planning care for the client. Drag from Word Choices to complete the sentence. The nurse is planning interventions to reduce the client's risk of dropdown, dropdown and dropdown.

Patient Data Exhibits The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.

A primigravida client at 32-weeks gestation presents to the clinic with a report of a pounding headache. The client demonstrates hyperreflexia. The nurse should recognize the client's symptoms may be caused by which condition?

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Patient Data Exhibits The nurse is reviewing the client's admission information. Which signs or symptoms warrant immediate follow-up by the nurse? Select all that apply.

Patient Data Exhibits The nurse is evaluating the infant's progress and the parents' understanding of the condition. For each finding, click to indicate if it supports the interventions were effective or does not support the interventions were effective.

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. (3,402 grams), weighs 7 lbs (3.175 grams) today?