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 D
Explanation
A. Instruct the child to gargle using salt water every 4 hr: Gargling can irritate the surgical site and increase the risk of bleeding.
B. Give the child fluids using a straw: Using a straw creates suction, which can dislodge the clot and cause bleeding.
C. Ask the child to take deep breaths and cough every 30 min: Coughing can increase pressure on the surgical site and lead to bleeding.
D. Apply an ice collar to the child's neck. An ice collar reduces swelling, pain, and the risk of bleeding by promoting vasoconstriction.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The infant is at risk for developing aspiration pneumonia and esophageal strictures.
Rationale:
- Aspiration pneumonia: GER can cause stomach contents to enter the respiratory tract, leading to aspiration pneumonia.
- Esophageal strictures: Chronic irritation from stomach acid can result in scarring and narrowing of the esophagus.
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