A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, which of the following findings should the nurse use to determine that the procedure was effective?

Choice A reason: Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.

Choice B reason: Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.

Choice C reason: Preparing for nasotracheal intubation is the priority action for a child who has signs of epiglottitis, as it can prevent airway obstruction and respiratory failure. The nurse should have the equipment and personnel ready for intubation and avoid any stimulation or manipulation of the throat that can trigger laryngeal spasm.

Choice D reason: Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.

Choice A reason: This statement is normal, as an infant who is 2 months old should have an axillary temperature between 36.5°C and 37.5°C (97.7°F and 99.5°F). The nurse should assess the infant's temperature using an axillary or tympanic method, as oral and rectal methods are not recommended for infants.

Choice B reason: This statement is normal, as an infant who is 2 months old should have a heart rate between 100 and 160 beats per minute. The nurse should assess the infant's heart rate by auscultating the apical pulse for a full minute.

Choice C reason: This statement is normal, as an infant who is 2 months old should have a respiratory rate between 25 and 40 breaths per minute. The nurse should assess the infant's respiratory rate by observing the chest movements for a full minute.

Choice D reason: This statement is abnormal, as an infant who is 2 months old should have a weight gain of about 150 to 200 grams (5 to 7 ounces) per week. The current weight of the infant indicates a failure to thrive, as it is below the 5th percentile for the age and gender. The nurse should report this finding to the provider and assess the infant's feeding habits, growth chart, and developmental milestones.