A nurse in a clinic is assessing a 9-month-old infant.
Which of the following findings requires further intervention?

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 88% on room air to 94% on 2 L/min O2) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 40 breaths/min to 32 breaths/min) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice E rationale:

Pulse rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in pulse rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

Choice F rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of mild bilateral expiratory wheezes and diminished breath sounds in the bases indicates some improvement compared to the initial assessment.

Choice G rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

The correct answer is Choice B.

Choice A rationale

Insulin should be administered subcutaneously, not intramuscularly. Rotating sites is important to prevent lipodystrophy, but the correct technique involves subcutaneous injection.

Choice B rationale

Drawing up the short-acting insulin into the syringe first is correct. This prevents contamination of the short-acting insulin vial with long-acting insulin, ensuring accurate dosing.

Choice C rationale

Wiping off the needle with an alcohol swab is not recommended. The needle should remain sterile, and only the top of the insulin vial should be wiped with an alcohol swab.

Choice D rationale

Administering insulin at a 30-degree angle is incorrect. Insulin should be administered at a 90- degree angle if the person can grasp 2 inches of skin, or at a 45-degree angle if only 1 inch of skin can be grasped.