Phase 3:
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.
After implementing the appropriate nursing interventions, the nurse assesses the infant. For each assessment finding listed, place the finding in the appropriate category based on whether the nursing and collaborative intervention was effective (helped to meet expected outcome), ineffective (did not help to meet expected outcomes), or unrelated (not related to the expected outcome)
Significant nasal congestion remains
Infant is pink and responsive to stimulation
Temperature is 100.7 F
Subclavicular intercostal and subcostal retractions
Respirations: 69 breathes/minute, saturation: 98% on 2L via HHFNC
Infant has a wet diaper
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Effective (Helped Meet Expected Outcome)
Infant is pink and responsive to stimulation: Indicates improved oxygenation and neurological status.
Respirations: 69 breaths/min, saturation: 98% on 2L via HHFNC: Oxygenation has improved with supplemental oxygen, though the rate is still elevated. Nonetheless, SpO₂ is now within normal range.
Infant has a wet diaper: Suggests adequate hydration and renal perfusion, which is a positive outcome of supportive care.
Ineffective (Did Not Help Meet Expected Outcome):
Significant nasal congestion remains: Indicates suctioning or airway clearance interventions were insufficient or need to be repeated.
Subclavicular intercostal and subcostal retractions: Continued increased work of breathing means respiratory distress is still present.
Unrelated (Not Related to Expected Outcome):
Temperature is 100.7 °F: Mildly elevated, but not central to assessing respiratory effort or hydration in this scenario. It does not directly reflect effectiveness of current interventions for respiratory distress or hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["C","D"]
Explanation
A. “It will be hard for you to continue taking dance and gymnastics now that you have been diagnosed with diabetes mellitus type 1.” This is discouraging and incorrect. Children with T1DM can participate in physical activities, which are actually encouraged as part of a healthy lifestyle—with careful glucose monitoring.
B. “You may have a hard time making friends who understand your diagnosis.” This is nontherapeutic and pessimistic. It can lead to feelings of isolation and is not supportive or solution-focused. Social support and inclusion are vital for emotional health.
C. “You will always have diabetes mellitus type 1, but this does not mean that you cannot be a normal child.” This is a realistic yet hopeful response. It acknowledges the chronic nature of T1DM while affirming that the child can still live a fulfilling life. It promotes emotional well-being and resilience.
D. “You will need to monitor your blood sugar and carbohydrate intake, but you can still participate in your favorite activities.” This reinforces the concept of normalcy and independence while emphasizing the importance of disease management. Children with T1DM are encouraged to stay active and engaged in activities, with appropriate planning and monitoring.
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