A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. What should the nurse do next?
Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.
Have the mother attempt to bottle feed the infant.
Assure the mother that these signs are normal symptoms of a cold.
Recognize that these are serious signs, and contact the physician.
The Correct Answer is D
A. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure: While congenital heart disease can present with respiratory distress, the presence of nasal flaring and retractions in an infant with a prolonged upper respiratory infection strongly suggests respiratory distress due to a pulmonary cause, such as bronchiolitis or pneumonia. A cardiac assessment may be necessary, but immediate intervention for respiratory distress is the priority.
B. Have the mother attempt to bottle feed the infant: Infants in respiratory distress often struggle with feeding due to increased work of breathing. Attempting to bottle feed could further compromise oxygenation and increase fatigue, worsening the child's condition.
C. Assure the mother that these signs are normal symptoms of a cold: Nasal flaring and intercostal retractions are signs of increased respiratory effort, indicating significant respiratory distress rather than a mild viral upper respiratory infection. These findings warrant prompt medical evaluation.
D. Recognize that these are serious signs, and contact the physician: Nasal flaring, sternal retractions, and intercostal retractions indicate significant respiratory distress, which can rapidly progress to respiratory failure in infants. Immediate assessment and intervention by a healthcare provider are necessary to ensure appropriate treatment and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The purpose of the tubes is to decrease the pressure and allow for drainage: Tympanostomy tubes are placed in the tympanic membrane to facilitate drainage of middle ear fluid and equalize pressure. They help prevent recurrent otitis media and improve hearing in children prone to persistent effusions. The tubes create a temporary opening that allows air to enter the middle ear, reducing the risk of fluid accumulation and infection.
B. The tubes are permanently inserted during a surgical procedure: Tympanostomy tubes are not permanent; they usually fall out on their own within 6 to 12 months as the tympanic membrane heals. In some cases, if they do not extrude naturally, they may need to be removed by an ear, nose, and throat (ENT) specialist. Permanent tubes are rarely used and only in cases of severe chronic ear problems.
C. The tubes are placed in the inner ear: Tympanostomy tubes are inserted into the tympanic membrane (eardrum), which separates the outer ear from the middle ear. They do not enter the inner ear, which contains the cochlea and vestibular system. Placement in the inner ear would not be anatomically correct and could lead to serious complications.
D. The tubes are used in children with sensorineural loss: Tympanostomy tubes are not a treatment for sensorineural hearing loss, which results from damage to the inner ear or auditory nerve. They are used for conductive hearing issues caused by middle ear effusion, recurrent ear infections, or Eustachian tube dysfunction. Sensorineural hearing loss is typically managed with hearing aids or cochlear implants, not tympanostomy tubes.
Correct Answer is ["A","D"]
Explanation
A. Intercostals: The intercostal muscles, including the external and internal intercostals, are primary muscles of respiration. They play a crucial role in expanding and contracting the thoracic cavity during inhalation and exhalation, facilitating airflow into and out of the lungs.
B. Scalene: The scalene muscles assist in elevating the first two ribs during deep inhalation, making them accessory muscles of respiration rather than primary muscles. They support breathing but are not the main muscles involved in the normal respiratory cycle.
C. Sternomastoid: The sternocleidomastoid muscles are also considered accessory muscles of respiration. They help elevate the sternum during forced inhalation, but they are not classified as primary muscles of respiration, which are more involved in the regular breathing process.
D. Diaphragm: The diaphragm is the primary muscle of respiration and is crucial for normal breathing. It contracts and flattens during inhalation, increasing the volume of the thoracic cavity and allowing air to flow into the lungs. This muscle is essential for the majority of airflow during normal breathing.
E. Pectoralis major: The pectoralis major is primarily involved in shoulder movement and is not a primary muscle of respiration. Although it can assist during forceful inhalation when the arms are raised, it does not function as a main muscle in the respiratory process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.