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 C
Explanation
A. Rubella: Rubella is a viral infection caused by the rubella virus, not a complication of untreated strep throat. It is unrelated to Group A Streptococcus (GAS) infection and is prevented through vaccination.
B. Leukoplakia: Leukoplakia is a condition characterized by white patches on the mucous membranes, often associated with chronic irritation or tobacco use. It is not a complication of streptococcal pharyngitis.
C. Rheumatic fever: Untreated streptococcal throat infections caused by Group A Streptococcus can lead to rheumatic fever, an inflammatory disease affecting the heart, joints, skin, and brain. This autoimmune response can result in rheumatic heart disease, which may cause permanent cardiac damage.
D. Scarlet fever: While scarlet fever can develop from strep throat, it is not a long-term complication but rather an acute reaction to the streptococcal toxin. The more serious complication of untreated strep throat is rheumatic fever, which can have lasting consequences, particularly for the heart.
Correct Answer is D
Explanation
A. Is impaired in a patient with cataracts: Cataracts primarily cause lens opacity, leading to blurry vision and reduced acuity. They do not directly affect extraocular muscle function, which is controlled by cranial nerves rather than the lens.
B. Is always decreased in the older adult: Aging can cause minor changes in eye movement speed and coordination, but significant impairment is not inevitable. Extraocular muscle function remains intact unless affected by neurological conditions such as cranial nerve palsy.
C. Is stimulated by cranial nerves (CNS) I and II: Cranial nerve I (olfactory) is responsible for smell, and cranial nerve II (optic) transmits visual signals to the brain. Neither nerve controls eye movement, which is instead governed by different cranial nerves.
D. Is stimulated by cranial nerves III, IV, and VI: The oculomotor (III), trochlear (IV), and abducens (VI) nerves control extraocular muscle movement. They coordinate eye positioning, alignment, and smooth tracking, ensuring proper function of the visual system.
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