A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)

Warm extremities

Wheezing

Nasal flaring

Retraction of sternal muscles

Oxygen saturation 95%

Answer and Explanation

Correct Answer : B,C,D

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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Correct Answer is D

Explanation

This position, often referred to as the "knee-to-chest" position, is recommended during a cyanotic spell in infants with tetralogy of Fallot because it can help increase venous return to the heart and improve oxygenation. It's important for caregivers to understand this positioning as part of the management for hypercyanotic spells in children with this condition.

A. Placing the baby upright in an infant seat may help improve blood flow and oxygenation, but it's not the recommended position for managing cyanosis in a baby with tetralogy of Fallot.

B. Placing the baby with the head lower than the rest of the body could potentially worsen cyanosis by increasing right-to-left shunting of blood and decreasing pulmonary blood flow.

C. Placing the baby in a supine position with the head elevated worsens pulmonary blood flow by increasing systemic vascular resistance. This position can help worsen cyanosis by promoting better oxygenation.

A. Reassure the mother that the tubes will not fall out. B. Take the child to an emergency department. C. Gently reinsert the tubes. D. Call the health care clinic to report that the tubes have fallen out.

Correct Answer is D

Explanation

D. If the tympanostomy tubes fall out, the parent should contact the healthcare clinic or the healthcare provider who performed the procedure. They can provide guidance on whether the child needs to be seen for an evaluation and potential replacement of the tubes. Reporting the situation allows for appropriate follow-up and management by the healthcare team.

A. Tympanostomy tubes are small tubes inserted into the eardrums to help drain fluid from the middle ear and prevent recurrent ear infections. While they are designed to stay in place for a certain period, it is possible for them to fall out prematurely.

B. It's important for the parent to seek medical advice if the tubes fall out but it may not always require an immediate visit to the emergency department. However, if the child experiences severe pain, bleeding, or signs of infection after the tubes fall out, seeking urgent medical attention may be warranted.

C. Only a healthcare provider should insert or reinsert tympanostomy tubes. Attempting to reinsert the tubes at home without proper training and equipment could cause injury or damage to the ear.

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

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Correct Answer is D

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Correct Answer is D

Explanation

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)