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 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 C
Explanation
A. A low erythrocyte sedimentation rate (ESR) is not typical in Kawasaki disease; the ESR is usually elevated due to inflammation.
B. Abdominal pain and vomiting can occur, but they are not as classic as the fever, "strawberry tongue", and peeling of palms and soles.
C. Fever, "strawberry tongue", and peeling palms and soles are classic signs of acute Kawasaki disease, reflecting inflammation and mucocutaneous involvement.
D. Coarse breath sounds and abnormal ECG may occur, but are not primary features of Kawasaki disease; joint pain can occur but is usually less prominent.
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