A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/minute.
Resting respiratory rate of 35 breaths/minute.
The Correct Answer is A
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While inspecting the infant’s ears daily can help detect signs of an ear infection early, it does not prevent recurrent otitis media.
Choice B rationale
Positioning the infant prone after feeding does not prevent recurrent otitis media and can actually increase the risk of sudden infant death syndrome.
Choice C rationale
While breastfeeding frequently can provide numerous health benefits for the infant, it does not specifically prevent recurrent otitis media.
Choice D rationale
Avoiding exposure to smoke can help prevent recurrent otitis media in infants. Smoke can irritate the Eustachian tubes, which can lead to fluid buildup and increase the risk of ear infections.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Age of the client is not a significant risk factor for postpartum hemorrhage. While age can influence overall health and pregnancy complications, it is not directly linked to an increased risk of postpartum hemorrhage. Therefore, the age of the client, in this case, does not increase the risk for postpartum hemorrhage.
Choice B rationale
The use of forceps during delivery can increase the risk of postpartum hemorrhage. Forceps delivery is an assisted delivery method which can cause trauma to the birth canal, leading to increased bleeding after delivery. In this case, the client had a forceps-assisted delivery, which could increase her risk for postpartum hemorrhage.
Choice C rationale
A 4th degree laceration is a severe tear that occurs during delivery, extending to the anal sphincter and rectal mucosa. This type of laceration can lead to significant blood loss and increase the risk of postpartum hemorrhage. In this case, the client had a 4th degree laceration, which increases her risk for postpartum hemorrhage.
Choice D rationale
A long labor duration can increase the risk of postpartum hemorrhage. Prolonged labor can lead to uterine atony, a condition where the uterus does not contract properly after delivery, leading to increased bleeding. In this case, the client was in labor for 25 hours, which could increase her risk for postpartum hemorrhage.
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