A nurse is collecting data from an infant whose guardian reports worsening symptoms.
The infant has a cough productive of very thick white mucus.
Upon auscultation, wheezes are heard bilaterally on inspiration and expiration.
Moderate substernal and subcostal retractions are noted.
Mucous membranes are pink, and a large amount of clear to white nasal discharge is noted.
Capillary refill is 2 to 3 seconds.
The guardian states the infant has difficulty feeding, often vomits, and has not had a wet diaper for 8 hours.
During coughing episodes, mucous membranes are cyanotic, and oxygen saturation decreases.
Which of the following actions should the nurse take first?

Choice A rationale

Administering oxygen therapy addresses hypoxemia caused by cyanotic episodes and decreased oxygen saturation. Supplemental oxygen improves alveolar oxygenation and enhances oxygen delivery to tissues. Cyanosis during coughing episodes indicates compromised respiratory function due to mucus obstruction, increasing oxygen demand. Normal oxygen saturation for infants is 95%-100%. The immediate priority is stabilizing oxygen levels to prevent respiratory distress and hypoxic injury, ensuring the infant receives adequate oxygenation until further interventions are implemented.

Choice B rationale

Encouraging oral hydration helps alleviate dehydration and thin mucus secretions. The infant’s lack of wet diapers for 8 hours signifies potential dehydration due to vomiting and inadequate feeding. While hydration supports overall respiratory health, it does not directly address the acute hypoxemia observed during cyanotic episodes. Normal urine output for infants is at least 1 mL/kg/hour. Priority action targets the most critical symptoms, rendering hydration a secondary measure after oxygen administration.

Choice C rationale

Placing the infant in an upright position improves ventilation and drainage of mucus secretions, reducing airway obstruction. Upright positioning alleviates the work of breathing by optimizing lung expansion. While beneficial, positioning alone cannot resolve hypoxemia during cyanosis or acutely improve oxygen saturation. Infants with significant respiratory distress require interventions like oxygen therapy to stabilize life-threatening symptoms prior to supportive measures such as positioning.

Choice D rationale

Preparing for emergency intubation ensures airway patency during severe respiratory compromise. Intubation may become necessary if hypoxemia persists despite oxygen therapy or if mucus obstruction worsens. However, immediate intubation bypasses less invasive initial measures. Oxygen therapy is prioritized to stabilize oxygen levels, allowing reassessment of respiratory status before advancing to more aggressive interventions.