A nurse is caring for a child who has otitis media.
Which of the following assessment findings should the nurse expect?

The correct answer is Choice C.

Choice A rationale

Administering an inhaled glucocorticoid can help reduce inflammation in the airways, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilation.

Choice B rationale

Obtaining a peak flow reading can help assess the severity of the asthma exacerbation, but it is not the priority intervention. The primary concern is to provide rapid bronchodilation.

Choice C rationale

Administering a short-acting beta-agonist (SABA) is the priority intervention. SABAs, such as albuterol, provide rapid bronchodilation and relieve bronchospasm, which are the main features of status asthmaticus.

Choice D rationale

Determining the cause of the acute exacerbation can help guide long-term management, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilation.

A. Inspection: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B. Auscultation: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C. Superficial palpation: This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D. Deep palpation: This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.