A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?

Choice A rationale

Allowing the toddler to inspect the stethoscope helps to reduce anxiety and build trust during the examination. This approach can make the child feel more comfortable and cooperative, facilitating a smoother and more thorough assessment.

Choice B rationale

While removing outer clothing is necessary for certain examinations, it should be done in a manner that respects the toddler's comfort and privacy. Gradually introducing the examination process is often more effective.

Choice C rationale

Performing traumatic procedures first can increase the toddler's anxiety and resistance to further examination. It is better to start with less invasive procedures to build trust and cooperation.

Choice D rationale

Allowing the toddler to sit in the parent's lap can provide comfort and reduce anxiety during the examination. This approach supports a more positive experience for the child.

Condition: Viral Upper Respiratory Infection (URI).

2 actions:

• Administer saline nasal drops,
• Encourage oral hydration.

2 parameters:

• Respiratory rate,
• Oxygen saturation.

Rationale for correct condition: A viral upper respiratory infection (URI) is indicated by the infant's symptoms of nasal congestion, cough, and mild intercostal retractions. The clear breath sounds suggest the absence of lower respiratory tract infection. The fever and irritability are consistent with a viral infection. The normal oxygen saturation level supports a less severe respiratory condition. The history of reduced feeding aligns with the discomfort caused by nasal congestion.

Rationale for actions: Administering saline nasal drops helps to relieve nasal congestion, improving the infant's breathing and comfort. Saline is safe and effective for clearing nasal passages in infants. Encouraging oral hydration ensures the infant remains well-hydrated, which is crucial for overall health and recovery. Adequate hydration helps thin mucus secretions, making it easier for the infant to breathe. Administering nebulized albuterol is more appropriate for bronchiolitis or asthma. Obtaining a chest X-ray is unnecessary without signs of pneumonia. Starting supplemental oxygen is not indicated with normal oxygen saturation.

Rationale for parameters: Monitoring respiratory rate helps assess the infant's breathing pattern and detect any signs of respiratory distress. Changes in respiratory rate can indicate worsening or improvement of the condition. Oxygen saturation monitoring ensures the infant maintains adequate oxygen levels, crucial for identifying any need for supplemental oxygen. Serum electrolyte levels are not directly related to a URI. Capillary refill time is important but not specific to respiratory conditions. Urine output monitors hydration but is less specific for respiratory assessment.

Rationale for incorrect conditions: Bronchiolitis presents with more severe respiratory distress and wheezing. Pneumonia would show abnormal lung sounds and possibly a higher fever. Foreign body aspiration would cause sudden onset of symptoms and possibly localized wheezing or stridor.