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. .

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Correct Answer is D

Explanation

Choice A rationale

Group therapy can be beneficial for individuals with substance abuse issues as it provides support, reduces isolation, and promotes healthy coping mechanisms. However, it is not the primary intervention for ensuring the health of the baby in a pregnant client on methadone.

Choice B rationale

Discontinuing methadone abruptly is dangerous and can lead to withdrawal symptoms, which can harm both the mother and the fetus. It is important to continue methadone treatment under medical supervision to prevent complications.

Choice C rationale

Genetic testing protocols are important for identifying potential genetic disorders but do not directly address the immediate health needs of a baby born to a mother on methadone treatment.

Choice D rationale

Starting a prenatal care plan as soon as possible is crucial for monitoring the health and development of the fetus, managing the mother's methadone treatment, and providing necessary interventions to ensure the baby's well-being. It is the best approach to ensure a healthy pregnancy.

A. Bleeding tendencies. B. Fluid balance. C. Heat loss. D. Hypoglycemia.

Correct Answer is C

Explanation

Choice A rationale

While bleeding tendencies can be a concern in newborns, especially if there are clotting disorders, it is not the immediate priority in the first minutes after birth. Immediate interventions focus on establishing effective respirations and ensuring adequate oxygenation.

Choice B rationale

Fluid balance is important for newborns, particularly in the context of hydration and potential complications like hypovolemia. However, the most immediate concern after birth is ensuring the newborn can breathe adequately to deliver oxygen to the body's tissues.

Choice C rationale

Heat loss is a critical issue for newborns, as they are at high risk for hypothermia due to their large surface area relative to body weight and limited ability to generate heat. Preventing heat loss helps to stabilize the newborn's temperature and supports overall physiological stability, including respiratory function.

Choice D rationale

Hypoglycemia can be a concern in newborns, particularly those who are small for gestational age or have other risk factors. However, the most immediate concern in the first minutes after birth is ensuring adequate breathing to support oxygenation and prevent complications related to hypoxia. .

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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

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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?