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 A

Explanation

Choice A rationale

Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.

Choice B rationale

Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.

Choice C rationale

Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.

Choice D rationale

Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.

A. Return of the uterus to prepregnancy size. B. Stimulation of uterine contractions. C. Activation of the let-down reflex. D. Expulsion of the placenta.

Correct Answer is B

Explanation

Choice A rationale

Oxytocin is not involved in returning the uterus to its prepregnancy size. Instead, it helps in uterine contractions, which facilitate the expulsion of the placenta and reduce postpartum bleeding. The process of uterine involution, returning to prepregnancy size, is primarily managed by the natural decline of pregnancy hormones and autolysis of uterine tissue.

Choice B rationale

Oxytocin stimulates uterine contractions, which is its primary function during labor and after delivery. These contractions help deliver the baby during labor and facilitate the expulsion of the placenta. After delivery, oxytocin continues to induce contractions to minimize postpartum hemorrhage and aid uterine involution.

Choice C rationale

Oxytocin can activate the let-down reflex for breastfeeding, but it is not the primary expected outcome when administered IV after delivery. The main goal post-delivery is to manage uterine contractions to prevent hemorrhage and assist in expelling the placenta.

Choice D rationale

While oxytocin assists in expelling the placenta by stimulating contractions, this is not its primary use post-delivery. The placenta typically detaches and is delivered shortly after birth. Oxytocin's main role after delivery is to continue stimulating contractions to reduce bleeding and help the uterus return to a non-pregnant state.

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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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Explanation

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Correct Answer is B

Explanation

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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?