The mother of an infant who has been treated for recurrent respiratory infections asks the nurse why infants are at increased risk for respiratory infections.


What is the best response by the nurse?

Choice A rationale

Dehydration in infants can be a serious medical concern if not addressed quickly. It can be caused by various factors such as vomiting or diarrhea, or if the baby is not nursing well. The most common signs of dehydration in babies include concentrated urine that looks very dark yellow or orange, constipation, dry lips, dry mouth, dry mucous membranes, excessive sleepiness, irritability, less than six wet diapers in a 24-hour period, no interest in taking a bottle or breastfeeding, no tears when crying, paleness, sunken fontanelle (soft spot) on their head, and wrinkled skin. If the nurse observes these signs and symptoms in the infant, along

with the intake and output record from the previous 8 hours, the nurse might determine that the patient is dehydrated during the shift.

Choice B rationale

If the infant shows signs of improvement such as increased urine output, normal skin turgor, moist mucous membranes, and the infant is alert and active, then the nurse might determine that the patient is improving as anticipated. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice C rationale

Fluid volume excess, also known as fluid overload, occurs when the body has too much water and electrolytes. Symptoms can include swelling in the hands, feet, ankles, or abdomen, weight gain, high blood pressure, and shortness of breath. If the nurse observes these symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might determine that the patient has fluid volume excess. However, given the information provided, this does not seem to be the most likely scenario.

Choice D rationale

If the infant’s vital signs are stable, the infant is alert and active, and there are no significant changes in the infant’s condition, the nurse might determine that the patient’s condition is stable. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice A rationale

A 6-month-old who has a high fever, dysphagia, stridor, and a muffled cry. This child is showing signs of epiglottitis, a severe and life-threatening condition that requires immediate medical attention. Epiglottitis is characterized by inflammation and swelling of the epiglottis, the flap at the base of the tongue that keeps food from going into the windpipe. Symptoms include high fever, difficulty swallowing (dysphagia), stridor (a high-pitched wheezing sound caused by disrupted airflow), and a muffled or hoarse voice. In severe cases, it can lead to complete blockage of the airway, which is a medical emergency.

Choice B rationale

A 13-year-old who has a high fever, stridor, and purulent secretions. While these symptoms are concerning and require medical attention, they are not as immediately life-threatening as the symptoms presented in Choice A. The presence of purulent secretions suggests a bacterial infection, which while serious, can typically be treated with antibiotics.

Choice C rationale

A 2-year-old who has a barky cough, is afebrile, and has mild intercostal retractions. These symptoms suggest croup, a common childhood condition that causes a barky cough and mild breathing difficulties. While croup can be distressing, it is usually not life-threatening and can often be managed at home with supportive care.

Choice D rationale

A 5-year-old who has an abrupt onset of moderate respiratory distress, a mild fever, and a barky cough. These symptoms also suggest croup. While this child is experiencing moderate respiratory distress, which requires medical attention, it is not as immediately life-threatening as the symptoms presented in Choice A2.