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. "My child will be awake for this procedure.": Incorrect because the child will be under sedation or anesthesia for safety and to prevent distress.
B. "I can take my child home as soon as the procedure is over.": Incorrect because the child must be monitored post-procedure for complications like airway swelling or sedation effects.
C. "The provider will remove the object during this procedure." A bronchoscopy allows visualization and removal of foreign objects from the airway, which is the purpose of the procedure.
D. "After this procedure, I have to wait 48 hours before I can give my child solid foods.": Incorrect because eating is typically resumed after the child recovers from sedation and demonstrates a safe swallow reflex.
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.
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