Phase 1
A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.
Select and highlight the assessment findings that require follow up.
Phase 1
A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.
Medical History
Up to date with vaccine
No known allergies
Born at 39 weeks
mild intercostal retractions
RR: 65 breaths/min
HR: 178
his capillary refill is >4 seconds
O2 Sat: 92% on RA
wheezing is heard bilaterally
Unable to stay latched to breast
Up to date with vaccine
No known allergies
Born at 39 weeks
The Correct Answer is ["A","B","C","D","E","F","G"]
Inability to stay latched to the breast is concerning because it reflects increased work of breathing or fatigue. Infants often show feeding difficulties as an early sign of respiratory compromise, and in this case, poor feeding may also contribute to dehydration and hypoglycemia.
Capillary refill greater than 4 seconds suggests delayed peripheral perfusion, which can indicate dehydration or early shock. This is a red flag in infants and requires prompt assessment of circulatory status.
Intermittent wheezing in both lungs is an abnormal breath sound typically associated with airway narrowing or obstruction, as seen in bronchiolitis or reactive airway disease. It requires close monitoring for worsening respiratory effort or decreased air exchange.
Heart rate of 178 beats per minute is elevated for a 10-week-old infant (normal is generally 100–160 bpm). This tachycardia may be a response to fever, hypoxia, respiratory distress, or dehydration, and should be evaluated in the context of other clinical signs.
Oxygen saturation of 92% on room air is below the expected range for a healthy infant (typically ≥95%). This indicates hypoxemia, and supplemental oxygen and further respiratory support may be necessary.
Respiratory rate of 65 breaths per minute exceeds the normal range for this age (30–60 breaths/min). Tachypnea can reflect respiratory distress and is especially concerning when paired with other abnormal findings.
Mild intercostal retractions are a sign that the infant is using accessory muscles to breathe, which indicates increased work of breathing. Even mild retractions in a young infant warrant close observation.
Restlessness and head bobbing are signs of significant respiratory distress. Head bobbing is particularly concerning as it indicates fatigue and the use of neck muscles to assist with breathing, which can precede respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F","H","I"]
Explanation
Dry lips and mucous membranes can indicate dehydration, which is common in children with diabetes mellitus type 1 (DM1) due to hyperglycemia. Dehydration in DM1 often results from osmotic diuresis, where excess glucose in the urine draws water out of the body, causing significant fluid loss. Immediate follow-up is needed to assess hydration status and possible management of the child's glucose levels and fluid intake.
The presence of enlarged lymph nodes can suggest an underlying infection or immune response. Although lymphadenopathy is commonly associated with infections, it is also important to investigate whether this could be related to diabetic ketoacidosis (DKA), as children with untreated or poorly controlled diabetes can be more prone to infections. This warrants follow-up for possible infection or other causes of lymphadenopathy.
Unexplained weight loss and an appearance of being thin, despite increased appetite (polyphagia), can be an early sign of diabetes type 1. The body begins breaking down fat and muscle tissue for energy when it cannot use glucose properly due to a lack of insulin. Immediate follow-up is necessary to assess blood glucose levels and determine if the child has undiagnosed diabetes.
A fruity or "sweet" odor on the breath, often described as similar to acetone, is a hallmark sign of diabetic ketoacidosis (DKA), a serious and potentially life-threatening complication of uncontrolled diabetes. This requires immediate follow-up as it indicates that the body is burning fat for fuel due to a lack of insulin, resulting in the production of ketones, which are excreted through the breath.
Anxiety can be associated with an underlying medical condition such as diabetes mellitus. Children with uncontrolled diabetes may feel anxious due to fluctuations in blood glucose levels or the physical symptoms associated with hyperglycemia or DKA. It’s important to address the cause of anxiety to ensure the child is receiving the appropriate treatment and emotional support.
A blood pressure of 96/44 mm Hg is on the lower side, and in the context of a child with suspected diabetes, this could suggest a state of dehydration or possible shock, especially if DKA is developing. Blood pressure changes must be followed up immediately to ensure appropriate treatment of dehydration or any circulatory compromise.
Weight: 15.9 kg: The child's weight (15.9 kg) in combination with the other symptoms (e.g., being thin, increased appetite) could indicate that the child is not gaining weight as expected, possibly due to undiagnosed type 1 diabetes. Immediate follow-up is required to assess growth patterns and consider possible conditions like diabetes that could affect normal weight gain.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A","dropdown-group-4":"A","dropdown-group-5":"A","dropdown-group-6":"A"}
Explanation
While assessing the child, the nurse recognizes that sweet breath odor, dry mucous membranes, and poor weight gain are signs of diabetes mellitus, a possible diagnosis. The nurse anticipates the provider will order the following tests: urinalysis and blood sugar to help confirm or rule out the diagnosis.
Rationale:
Sweet breath odor: A fruity or sweet odor, often described as acetone-like, is a classic sign of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. This occurs due to the breakdown of fats in the absence of sufficient insulin, producing ketones that are exhaled.
Dry mucous membranes: This is a common sign of dehydration, which can be caused by hyperglycemia in diabetes mellitus. High glucose levels lead to increased urine output and fluid loss.
Poor weight gain: Children with diabetes mellitus type 1 often experience unexplained weight loss despite increased appetite (polyphagia) because their bodies break down fat and muscle for energy due to insufficient insulin.
Most Likely Diagnosis:
Diabetes mellitus: The combination of symptoms (sweet breath odor, dry mucous membranes, and poor weight gain) strongly suggests diabetes mellitus, likely type 1 diabetes. This condition often presents with hyperglycemia, dehydration, and weight loss despite increased hunger.
Tests to Confirm or Rule Out the Diagnosis:
Urinalysis: This is used to check for the presence of glucose and ketones in the urine, which can help diagnose diabetes mellitus and diabetic ketoacidosis (DKA).
Blood sugar: A blood glucose test is essential for confirming diabetes mellitus. Elevated blood glucose levels are a hallmark of the disease, and testing will provide insight into the child’s current glucose levels, confirming or ruling out diabetes.
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