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. Pericardial sac: The pericardial sac, also known as the pericardium, is a double-walled sac that surrounds and protects the heart. It consists of an outer fibrous layer and an inner serous layer, which produces pericardial fluid to reduce friction between the heart and surrounding structures during heartbeats. This structure provides support and helps maintain the position of the heart within the thorax.
B. Endocardial sac: The endocardium is the innermost layer of the heart wall that lines the heart chambers and covers the heart valves. It does not refer to a protective sac surrounding the heart.
C. Pleural sac: The pleural sac consists of two layers (visceral and parietal pleura) that encase the lungs and provide a lubricated surface for lung expansion and contraction during respiration. It is not related to the heart.
D. Myocardial sac: The myocardium refers to the muscular middle layer of the heart wall responsible for contraction and pumping blood. It is not a sac and does not surround or protect the heart.
Correct Answer is D
Explanation
A. Lymphadenopathy: Enlarged lymph nodes typically indicate an immune response to infection or inflammation. While allergies can cause mild lymph node enlargement due to chronic irritation, they do not directly cause the characteristic facial signs described, such as the transverse nasal crease and allergic shiners.
B. Nasal congestion: Nasal congestion is a symptom rather than a primary diagnosis. Although allergies can cause nasal congestion, the child exhibits additional hallmark signs of allergic rhinitis, including allergic shiners, Dennie-Morgan lines, and a nasal crease, suggesting a chronic allergic process rather than isolated congestion.
C. Upper respiratory infection: Viral upper respiratory infections (URIs) can cause nasal congestion, sneezing, and watery eyes, but they are usually short-lived and accompanied by fever, malaise, or yellow-green nasal discharge. The presence of a nasal crease and allergic shiners suggests a chronic process like allergic rhinitis rather than an acute infection.
D. Chronic allergies: The presence of a transverse nasal crease from frequent "allergic salute" rubbing, dark periorbital circles (allergic shiners) due to venous congestion, and Dennie-Morgan lines (double creases under the eyes) are classic findings in allergic rhinitis. These symptoms, along with watery eyes and clear nasal drainage, strongly indicate a chronic allergic condition rather than an infectious cause.
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