A nurse is assessing a 2-month-old infant who has an acute respiratory tract infection, Which of the following findings should the nurse identify as requiring Intervention?
(Select All that Apply:)
Cyanotic skin
Nasal flaring
Productive cough
crying during feeding
Intercostal retractions
Head bobbing
Correct Answer : A,B,D,E,F
Rationale:
A. Cyanotic skin indicates hypoxia and is a medical emergency requiring immediate intervention.
B. Nasal flaring is a sign of increased respiratory effort and distress in infants.
C. Productive cough is uncommon in young infants and less likely to be observed due to their limited ability to expectorate secretions.
D. Crying during feeding may indicate difficulty breathing while feeding, a sign of respiratory compromise.
E. Intercostal retractions reflect increased work of breathing and respiratory distress.
F. Head bobbing is a late sign of respiratory distress in infants and suggests fatigue and possible impending respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Hearing screening is important, but not the immediate priority in a child who has missed routine visits.
B. Dental care should begin early, but updating immunizations takes precedence to prevent serious communicable diseases.
C. Updating vaccinations is the priority because the child is significantly behind on the recommended immunization schedule, placing them at risk for preventable infections.
D. Growth and development assessment is essential but can be done after addressing the urgent need for immunization.
Correct Answer is D
Explanation
Rationale:
A. Keeping the suspicion to oneself can delay necessary intervention and put the child at further risk.
B. Waiting for further evidence is not appropriate; nurses are mandated reporters and do not need to prove abuse—only to report suspicion.
C. Confronting the caregiver may escalate the situation and is not within the nurse’s role for handling suspected maltreatment.
D. Reporting to the appropriate agency (such as child protective services) is the correct and legal action required to protect the child and initiate proper investigation.
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