A nurse is caring for a 4-month-old infant.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Applying heat to the affected areas: Heat application promotes vasodilation and helps relieve pain in vaso-occlusive crises. This is a priority because managing pain is critical during a crisis. It can also help improve blood flow and alleviate discomfort.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: Bed rest is generally recommended to reduce energy expenditure, but it does not directly address the acute pain or vaso-occlusion that needs to be managed immediately.

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. B. Place the child in prone position. C. Stabilize the thermometer at the distal end. D. Direct the tip of the thermometer toward the spine during insertion.

Correct Answer is C

Explanation

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. The correct insertion depth is 2.5 cm (1 inch) for toddlers to avoid rectal injury.
B. Place the child in prone position. The child should be placed in the side-lying or supine position with legs flexed.
C. Stabilize the thermometer at the distal end. Stabilizing the thermometer ensures it remains in position during the procedure, minimizing risk of injury.
D. Direct the tip of the thermometer toward the spine during insertion. The thermometer should be directed toward the umbilicus to follow the natural rectal curve.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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