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Patient Data

Exhibits
The nurse is prioritizing care for the client. Select the 3 highest priority findings for the nurse to address.

Temperature

Refusing bottle

Signs of pain

Cough during feeding

Oxygen saturation

Formula coming from nares

Answer and Explanation

Correct Answer : B,D,E

Rationale:

A. Temperature: Mild fever (99.1°F/37.2°C) is present but has decreased from earlier measurements after acetaminophen administration. While it requires monitoring, it is not the most immediate priority compared with feeding and airway concerns.

B. Refusing bottle: Feeding refusal places the infant at high risk for dehydration and inadequate nutrition, especially in the presence of a submucous cleft palate. This requires prompt intervention to maintain hydration and caloric intake.

C. Signs of pain: Moderate pain is being managed with acetaminophen and sucrose, making it less urgent than airway and feeding issues at this time.

D. Cough during feeding: This suggests possible aspiration risk, especially in the context of a submucous cleft palate. It may lead to respiratory complications and requires immediate evaluation.

E. Oxygen saturation: Oxygen desaturation to 91% during feeding indicates potential airway compromise or aspiration, which requires immediate attention to prevent hypoxia.

F. Formula coming from nares: This is a classic symptom of a cleft palate and provides important diagnostic information. While it is a significant finding, it is not an acute, life-threatening problem that requires immediate nursing action.

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Correct Answer is A

Explanation

Rationale:

A. Situate in knee-chest position: Placing the infant in a knee-chest position increases systemic vascular resistance, which helps reduce right-to-left shunting and improves pulmonary blood flow during a hypercyanotic (“Tet”) spell to improve oxygenation and prevent hypoxic injury.

B. Perform chest physiotherapy: Chest physiotherapy is used to mobilize secretions in respiratory conditions but does not address the acute pathophysiology of a Tet spell. It would not rapidly improve oxygenation in this emergency.

C. Reduce flow rate of intravenous fluid replacement: Reducing IV fluids may decrease venous return but does not relieve the hypoxic crisis caused by right-to-left shunting. This intervention is not indicated during a hypercyanotic episode.

D. Administer prescribed morphine subcutaneously: Morphine can be used to calm the infant and reduce pulmonary resistance in some Tet spell protocols, but positioning the infant in a knee-chest posture is the first, immediate action to improve oxygenation before pharmacologic measures.

A. Flaring of the nares. B. Diaphragmatic respirations. C. Resting respiratory rate of 35 breaths/minute. D. Bilateral bronchial breath sounds.

Correct Answer is A

Explanation

Rationale:

A. Flaring of the nares: Flaring of the nares occurs when the infant is working harder to breathe and indicates increased respiratory effort. In the context of RSV with poor feeding and frequent coughing, this is a key sign of respiratory distress that requires prompt attention.

B. Diaphragmatic respirations: Diaphragmatic (abdominal) breathing is normal in infants and reflects typical respiratory mechanics. It does not indicate respiratory distress unless accompanied by other abnormal signs like retractions or nasal flaring.

C. Resting respiratory rate of 35 breaths/minute: A respiratory rate of 35 is within the normal range for a 4-month-old (30–60 breaths/minute). Alone, it does not signify distress, though trends or additional signs should be monitored.

D. Bilateral bronchial breath sounds: Bilateral bronchial breath sounds can be normal over the central airways. This finding does not indicate respiratory distress and may reflect normal auscultatory findings in infants.

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Patient Data Exhibits The nurse is prioritizing care for the client. Select the 3 highest priority findings for the nurse to address.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Patient Data

Exhibits
The nurse is prioritizing care for the client. Select the 3 highest priority findings for the nurse to address.