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?
A resting respiratory rate of 35 breaths/minute.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Flaring of the nares.
The Correct Answer is D
Choice A rationale
A resting respiratory rate of 35 breaths/minute for a 4-month-old infant is within the normal range (typically 30-60 breaths/minute). Therefore, this finding alone does not indicate acute respiratory distress.
Choice B rationale
Bilateral bronchial breath sounds are normal findings when auscultated over the trachea. However, their presence over the peripheral lung fields can indicate consolidation, such as in pneumonia. While abnormal in the periphery, it is not an isolated sign of acute respiratory distress.
Choice C rationale
Diaphragmatic respirations, also known as abdominal breathing, are the predominant and normal breathing pattern in infants and young children due to the preferential use of the diaphragm for respiration. This is not a sign of respiratory distress.
Choice D rationale
Flaring of the nares is a significant clinical sign of increased work of breathing and respiratory distress in infants. It indicates that the infant is attempting to decrease airway resistance and maximize oxygen intake by dilating the nasal passages. This is a compensatory mechanism indicating respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Describing the percentage of saturated perineal pads is a subjective and imprecise method for estimating blood loss. Variations in pad size, absorbency, and the client's perception can lead to significant inaccuracies, making it unreliable for precise clinical assessment of hemorrhage.
Choice B rationale
While hematocrit levels are crucial for assessing overall blood volume status, obtaining an hourly hematocrit is an indirect and reactive measure of acute blood loss. It reflects hemodilution or hemoconcentration over time rather than providing a real-time, accurate quantification of the volume of blood lost. Normal hematocrit for pregnant women is 33% to 44%.
Choice C rationale
Changes in vital signs, such as tachycardia, hypotension, and tachypnea, are late indicators of significant blood loss and hypovolemic shock. Relying solely on vital signs means that a substantial amount of blood has already been lost before changes become apparent, making it an insensitive method for early detection and estimation.
Choice D rationale
Calculating the difference in weight of perineal pads before and after use provides a highly accurate objective measurement of blood loss. One gram of weight is approximately equivalent to one milliliter of blood, allowing for precise quantification and enabling timely and appropriate clinical interventions.
Correct Answer is D
Explanation
Choice A rationale
Washing frequently with mild soap and water is not recommended for umbilical cord care because soap can irritate the delicate skin around the cord stump and potentially delay the natural drying and separation process. Excessive moisture also increases the risk of bacterial colonization and infection, counteracting the goal of keeping the area clean and dry to promote healing and reduce infection risk.
Choice B rationale
Applying baby lotion to the umbilical cord stump is contraindicated. Lotions introduce moisture, which can impede the natural drying and mummification of the cord, prolonging the time until it falls off. Furthermore, lotions contain chemicals that may irritate the sensitive skin or harbor bacteria, increasing the risk of infection and delaying proper healing of the umbilical area.
Choice C rationale
Covering the umbilical cord with a sterile dressing is generally not advised unless specifically indicated by a healthcare provider for a particular condition. A dressing can trap moisture, preventing adequate air circulation needed for drying, and potentially create a warm, moist environment conducive to bacterial growth. This increases the risk of infection and delays natural cord separation.
Choice D rationale
Cleaning the umbilical cord with water and allowing it to air dry is the most evidence-based practice for routine cord care. Water gently removes any discharge without irritating the skin, and air exposure facilitates the drying process, which is crucial for mummification and eventual detachment. This minimizes the risk of infection and promotes natural healing.
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