A 4-month-old with a temperature of 100.5° F (38.1° C) and an occasional cough is admitted to the pediatric unit with possible pneumonia.
Which assessment should alert the practical nurse (PN) that the infant is in acute respiratory distress?

Choice A rationale

Sweet potatoes are a gluten-free root vegetable. They are rich in vitamins, minerals, and fiber, and their consumption is safe for individuals with celiac disease or gluten sensitivity. The presence of antigliadin and antiendomysial antibodies indicates a gluten-related disorder, necessitating avoidance of gluten-containing grains, not sweet potatoes.

Choice B rationale

Wheat bread contains gluten, a protein complex found in wheat, barley, and rye. Antigliadin and antiendomysial antibodies are serological markers for celiac disease, an autoimmune disorder triggered by gluten ingestion, leading to small intestinal damage. Therefore, individuals with these antibodies must avoid gluten-containing foods like wheat bread to prevent symptomatic flares and intestinal damage.

Choice C rationale

Orange juice is a gluten-free beverage, primarily composed of water, sugars, and vitamins. It does not contain any gluten-derived proteins. Its consumption is safe for individuals with celiac disease or gluten sensitivity, as it will not elicit an immune response or contribute to intestinal damage in those with antigliadin and antiendomysial antibodies.

Choice D rationale

Swiss cheese is a dairy product and naturally gluten-free. It consists primarily of milk proteins, fats, and calcium, with no gluten-containing grains. Individuals with celiac disease or gluten sensitivity can safely consume Swiss cheese without triggering an immune response, as it does not contain the specific proteins that activate antigliadin and antiendomysial antibodies.

Choice A rationale

Giving prescribed digoxin and furosemide is part of the long-term management for cardiac conditions, but these medications do not provide immediate relief for an acute hypoxic spell. Digoxin improves cardiac contractility, and furosemide promotes fluid excretion, but their onset of action is not rapid enough for emergent situations.

Choice B rationale

Returning the child to bed and elevating the head of the bed might provide some comfort but does not directly address the underlying physiological cause of the hypoxic spell. Elevating the head of the bed may slightly improve respiratory effort but won't reverse cyanosis effectively.

Choice C rationale

Offering to play a board game with the child as a distraction does not address the physiological emergency of a hypoxic spell. Distraction may be helpful for anxiety but is not an intervention for cyanosis, tachypnea, and tachycardia, which require medical intervention.

Choice D rationale

Providing oxygen increases the available oxygen for gas exchange, and promoting the knee-chest position reduces venous return to the heart, thereby decreasing right-to-left shunting and improving pulmonary blood flow in conditions like Tetralogy of Fallot, which commonly presents with "squatting" and hypoxic spells.