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 B
Explanation
A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.
Correct Answer is A
Explanation
A. Accompany verbal instructions with visual references. Children with ADHD benefit from multimodal teaching strategies. Combining verbal instructions with visual aids helps reinforce understanding and keeps the child focused.
B. Vary the classroom routine to keep the children interested: Children with ADHD thrive on consistency; frequent changes in routine can increase confusion and distractibility.
C. Limit presentation of subjects of interest to the afternoons: This is not evidence-based. Children’s ability to focus varies throughout the day, and important content should not be restricted to a specific time.
D. Increase classroom assignments to stimulate learning: Increasing workload can overwhelm a child with ADHD, leading to frustration and reduced engagement.
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