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. SA node → AV node → bundle branches → Purkinje fibers: The sinoatrial (SA) node, located in the right atrium, is the heart's natural pacemaker, initiating electrical impulses. These impulses travel to the atrioventricular (AV) node, where conduction slows to allow ventricular filling. The signal then moves through the bundle of His, dividing into the right and left bundle branches, and finally reaches the Purkinje fibers, which stimulate ventricular contraction. This is the correct sequence.
B. AV node → SA node → Purkinje fibers → bundle branches: The AV node does not initiate the electrical impulse under normal conditions; it receives the impulse from the SA node. The Purkinje fibers are the final part of the conduction pathway, not an intermediate step before the bundle branches.
C. Bundle branches → AV node → SA node → Purkinje fibers: Electrical conduction does not begin at the bundle branches. The SA node initiates the impulse, and the AV node delays transmission before passing the impulse to the ventricles via the bundle branches and Purkinje fibers.
D. AV node → SA node → bundle branches → Purkinje fibers: The SA node, not the AV node, initiates the cardiac cycle. The AV node functions as a relay station that briefly delays the impulse before it proceeds to the bundle branches and Purkinje fibers.
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.
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