A nurse is caring for a toddler who is hospitalized with respiratory syncytial virus (RSV). Which of the following nursing interventions is the priority?
Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F)
Encourage the child to drink small, frequent amounts of fluids
Monitor oxygen saturation and apply humidified oxygen if needed
Place the child on contact and droplet precautions
The Correct Answer is C
A. Fever is a common symptom of RSV, and antipyretics can improve comfort. However, fever itself is not life-threatening and does not directly address the risk of airway compromise or hypoxia. Therefore, antipyretics are secondary to interventions that support breathing and oxygenation.
B. Hydration is important because RSV can cause poor oral intake, dehydration, and increased mucus viscosity, which may worsen airway obstruction. While promoting fluids is necessary, it is not as urgent as ensuring adequate oxygenation.
C. Continuous monitoring of oxygen saturation allows for early detection of hypoxemia. Hypoxia can develop rapidly in infants and toddlers with RSV due to their smaller airway size and limited respiratory reserve. Humidified oxygen helps maintain airway moisture, reduces airway irritation, and supports gas exchange. Ensuring adequate oxygenation prevents complications such as respiratory failure, apnea, or cardiac compromise, making it the highest priority intervention.
D. RSV is highly contagious and spreads via respiratory droplets and direct contact. Precautions are essential to protect staff and other patients, but infection control measures do not address the immediate threat to the patient’s respiratory status. Priority interventions must first ensure the child’s airway and oxygenation are stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Referred pain occurs when pain is perceived in an area different from the site of the actual tissue damage (e.g., shoulder pain from gallbladder disease). In this scenario, the pain is localized to the joints, not referred, so this is incorrect.
B. Procedural pain is short-term pain associated with medical procedures such as injections, IV insertions, or surgeries. Persistent joint pain lasting 4 months is not related to a procedure, so this is incorrect.
C. Chronic pain is defined as pain that persists longer than 3 months or beyond the expected period of healing. This 13-year-old has had joint pain for 4 months, meeting the criteria for chronic pain. Chronic pain in juvenile arthritis can affect physical activity, school performance, and psychosocial well-being, and requires long-term management strategies.
D. Acute pain is short-term, sudden in onset, and usually associated with tissue injury or inflammation, typically resolving within days to weeks. Pain lasting 4 months exceeds the acute timeframe, so this is incorrect.
Correct Answer is D
Explanation
A. Rho(D) immune globulin is not given only after delivery. Administering it after delivery alone prevents sensitization for future pregnancies but does not provide prophylaxis during the current pregnancy.
B. The woman does not only receive Rho(D) immune globulin after her second pregnancy. Prophylaxis is necessary during the current pregnancy if she is Rh-negative and the fetus is at risk of being Rh-positive.
C. Rho(D) immune globulin is not given monthly during pregnancy. Standard prophylaxis involves a scheduled dose at 28 weeks gestation, with an additional dose postpartum if the newborn is Rh-positive. More frequent dosing is only indicated if there is a significant risk of fetal-maternal hemorrhage (e.g., miscarriage, trauma, amniocentesis).
D. The recommended schedule for Rh-negative women without prior sensitization is to receive a prophylactic dose of Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery if the newborn is Rh-positive. This prevents the mother’s immune system from producing antibodies against Rh-positive fetal red blood cells, reducing the risk of hemolytic disease in current or future pregnancies. Administration is also indicated after events that increase fetal-maternal blood mixing.
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