A nurse is caring for a 4-month-old infant.
Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the infant's progress.
The Correct Answer is []
Condition Most Likely Experiencing: Bronchiolitis
The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.
Actions to Take:
- Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
- Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.
Parameters to Monitor:
- Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
- Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 6 months: At this age, infants typically coo and babble but do not form words.
B. 10 months: Infants might say "mama" or "dada," but their vocabulary is usually less than 10 words.
C. 18 months: By 18 months, most children have a vocabulary of approximately 10–20 words.
D. 24 months: By 24 months, children typically have a vocabulary of about 50 words or more and begin forming two-word phrases.
Correct Answer is A
Explanation
A. Nutritionist. The toddler’s BMI (28) indicates obesity, necessitating a referral for nutritional counseling to guide healthier dietary practices.
B. Speech therapist. The toddler demonstrates age-appropriate speech development, including forming short sentences such as "want go home now."
C. Physical therapist. The toddler meets gross motor developmental milestones such as running, kicking, and throwing a ball.
D. Occupational therapist. The toddler’s ability to feed themselves using finger foods and utensils indicates appropriate fine motor skills.
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