Phase 2:
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.
Which complications will the nurse anticipate when caring for this infant?
Dehydration
Pulmonary edema
Infection
Apnea
Respiratory failure
Fatigue
Vomiting
Hypoxia
Correct Answer : A,D,E,F,H
A. Dehydration: The infant is unable to stay latched to breast, indicating poor feeding. Combined with increased work of breathing and restlessness, there's a high risk of inadequate fluid intake, which can quickly lead to dehydration in infants.
B. Pulmonary edema: This is not typically associated with bronchiolitis or viral respiratory infections in infants unless there’s cardiac involvement or fluid overload, which is not indicated here.
C. Infection: While the infant likely already has a viral infection (e.g., RSV), the term “infection” in this context refers to the development of a secondary or worsening infection, which is not an immediate complication unless symptoms progress.
D. Apnea: Young infants, especially those under 3 months, are at risk of apneic episodes when experiencing respiratory infections like bronchiolitis, which this case suggests. Apnea is a known complication, especially in infants under 2–3 months.
E. Respiratory failure: The infant is showing head bobbing, intercostal retractions, RR of 65, and low oxygen saturation — all signs of increasing respiratory distress that, if uncorrected, may progress to respiratory failure.
F. Fatigue: Sustained increased respiratory effort (e.g., tachypnea, retractions, restlessness) can lead to exhaustion, especially in infants with limited energy reserves. Fatigue may worsen breathing and feeding issues.
G. Vomiting: Not reported or directly suggested by the scenario. While some infants may vomit with coughing, it’s not a primary anticipated complication in this case.
H. Hypoxia: With an oxygen saturation of 92% on room air, and clinical signs of distress, hypoxia is already present and must be corrected to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Laryngitis is typically self-limiting and does not require emergency intervention.
B. Laryngotracheobronchitis (croup) can cause significant respiratory distress but is usually managed with supportive care unless severe.
C. Epiglottitis is a life-threatening condition that causes airway obstruction and requires immediate emergency intervention, including securing the airway and starting antibiotics.
D. Spasmodic croup can be distressing but generally resolves with supportive measures and is not an immediate emergency.
Correct Answer is B
Explanation
A. Adding rice cereal could cause excess work on the heart and worsen symptoms. The focus should be on low-stress feeding.
B. Knee-chest position increases systemic vascular resistance, which helps relieve hypercyanotic spells (tet spells) in infants with tetralogy of Fallot.
C. Trendelenburg position is not effective for relieving cyanosis in this condition.
D. The infant with tetralogy of Fallot should be fed smaller, more frequent meals rather than every 2 hours.
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