A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?

Diaphragmatic respirations.

Bilateral bronchial breath sounds.

Flaring of the nares.

A resting respiratory rate of 35 breaths/minute.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.

Choice B rationale

Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.

Choice C rationale

Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.

Choice D rationale

A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Covering the lesion with a dressing is not an appropriate action as it will not prevent the transmission of herpes to the newborn. Herpes simplex virus can be transmitted to the neonate during delivery, and covering the lesion does not eliminate the risk.

Choice B rationale

Blood cultures are not indicated for managing active herpes lesions in a client with spontaneous rupture of membranes. This action does not address the immediate risk of transmission of the virus to the newborn.

Choice C rationale

Preparing for a cesarean section is the appropriate action because it reduces the risk of neonatal herpes transmission. Neonatal herpes can lead to severe complications, and a cesarean section is recommended to minimize the risk of exposure to the virus during vaginal delivery.

Choice D rationale

Administering penicillin is not appropriate for treating herpes lesions. Penicillin is an antibiotic effective against bacterial infections, but herpes is caused by a virus. Antiviral medications are required to manage herpes infections.

A. Blood transfusion. B. Rubella vaccination. C. Penicillin G potassium. D. Hepatitis B immunoglobulin.

Correct Answer is B

Explanation

Choice A rationale

The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.

Choice B rationale

Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.

Choice C rationale

Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.

Choice D rationale

Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?