How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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?

A.

Dehydration

B.

Pulmonary edema

C.

Infection

D.

Apnea

E.

Respiratory failure

F.

Fatigue

G.

Vomiting

H.

Hypoxia

Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

A. It is important to acknowledge potential postoperative discomfort to set realistic expectations for recovery and reduce anxiety.

B. Allowing the child to hear the ECG monitor sounds helps familiarize them with the equipment and can reduce fear or anxiety.

C. Explaining that an endotracheal tube may be needed is more accurate than giving false reassurance, as it could be required during surgery.

D. Showing unfamiliar equipment to the child can help reduce fear by familiarizing them with what they may encounter.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Therapeutic Responses:

“By administering IV insulin and IV fluids, we can help your grandchild feel better.” This response is informative and reassuring without giving false hope. It focuses on the next steps in care and shows confidence in the treatment plan.

“It is important that you understand that this is not something you could have prevented.” This reduces feelings of guilt or blame, which is important when dealing with families learning about a chronic diagnosis.

“I understand all of this can be overwhelming, but we are here to support you through this new diagnosis.” This validates the caregivers’ feelings and offers emotional support, which is crucial in pediatric care.

Nontherapeutic Responses:

“There is no need to worry, this diagnosis is common in children.” This dismisses the caregivers’ valid emotions. While Type 1 diabetes is relatively common, minimizing their concern is not supportive.

“Yes, you could have attributed to this problem by not limiting the amount of sugar your grandchild eats.” This is blaming and factually incorrect, as Type 1 diabetes is an autoimmune condition and not caused by sugar intake.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register