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 C
Explanation
Choice A rationale
Preventing further disability is often challenging with established developmental disabilities, which typically involve permanent neurological or genetic conditions. Interventions focus on managing symptoms and optimizing function rather than halting the underlying progression, as the primary pathology is often non-progressive or already expressed.
Choice B rationale
While rehabilitation is an integral part of care for children with developmental disabilities, it serves as a means to an end, aiming to improve function and quality of life. The ultimate goal extends beyond mere rehabilitation to encompass holistic development and independent functioning.
Choice C rationale
The primary goal for a child with a developmental disability is to empower them to reach their highest possible level of physical, cognitive, social, and emotional functioning. This involves individualized interventions, therapies, and educational support tailored to their specific needs and strengths, fostering independence and participation.
Choice D rationale
Promoting social acceptability is an important aspect of care, as it contributes to the child's quality of life and integration into society. However, it is a secondary objective, stemming from the broader goal of helping the child develop their full potential and navigate social interactions effectively.
Correct Answer is A
Explanation
Choice A rationale
Gravida refers to the total number of pregnancies a woman has had, regardless of the outcome or duration. In this case, the client has had one miscarriage at 16 weeks, one fetal demise at 31 weeks, and is currently at 39 weeks gestation. Therefore, counting the current pregnancy along with the two previous pregnancies, the total gravida is 3 + 1 = 4.
Choice B rationale
Gravida 2 would inaccurately represent the total number of pregnancies. This calculation would exclude either the current pregnancy or one of the previous pregnancy losses, which contradicts the definition of gravida as the total count of all pregnancies.
Choice C rationale
Gravida 1 would be incorrect as it only counts the current pregnancy and completely disregards the two previous pregnancies, one ending in miscarriage and another in fetal demise. The term "gravida" encompasses all pregnancies, irrespective of outcome.
Choice D rationale
Gravida 3 would be incorrect as it would only account for the two previous pregnancies and the current one but would not include the miscarriage at 16-weeks gestation, which is still considered a pregnancy for gravida count. The current pregnancy is added to the total.
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