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 D
Explanation
A. Bronchial breath sounds that are normal in that location: Bronchial breath sounds are high-pitched and louder, with expiration lasting longer than inspiration. They are normally heard over the trachea and not over the posterior lower lobes. If bronchial sounds are heard in the lower lung fields, it may indicate lung consolidation, such as in pneumonia.
B. Bronchovesicular breath sounds that are normal in that location: Bronchovesicular breath sounds are moderate in pitch and intensity, with inspiration and expiration being roughly equal in length. These sounds are typically heard over the major bronchi, near the sternum anteriorly and between the scapulae posteriorly, making them unlikely to be present in the posterior lower lobes.
C. Normal sounds auscultated over the trachea: Breath sounds heard over the trachea are expected to be bronchial, which are loud and high-pitched, with expiration lasting longer than inspiration. The low-pitched, soft sounds described do not match the normal tracheal breath sounds.
D. Vesicular breath sounds that are normal in that location: Vesicular breath sounds are soft and low-pitched, with inspiration lasting longer than expiration. They are the normal breath sounds heard over most of the peripheral lung fields, including the posterior lower lobes, confirming that these findings are normal.
Correct Answer is A
Explanation
A. Whisper a set of random numbers and letters, and then ask the patient to repeat them: The whispered voice test is a simple and reliable screening method for hearing loss. The nurse stands about 2 feet behind the patient, whispers a series of random numbers or letters, and asks the patient to repeat them. This helps assess high-frequency hearing loss.
B. Shield the lips so that the sound is muffled: While the test is performed without the patient seeing the nurse’s lips to prevent lip reading, deliberately muffling the sound is unnecessary and may alter the accuracy of the assessment.
C. Stand approximately 6 feet away to ensure that the patient can really hear at this distance: The whispered voice test is conducted at a standard distance of about 2 feet, not 6 feet. Increasing the distance may make the test unreliable.
D. Ask the patient to place his or her finger in their ears to occlude outside noise: The test should be performed in a quiet environment, but instructing the patient to occlude their ears is unnecessary. Instead, the nurse tests one ear at a time by covering the opposite ear.
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