The nurse is planning care for a child in the acute phase of Kawasaki disease.
Which intervention is priority?

Choice A rationale

Severe retractions, involving the use of accessory muscles in the intercostal, subcostal, or supraclavicular regions, indicate an extremely high work of breathing and significant airway obstruction or severe lung compliance issues. This extreme muscular effort often signals imminent respiratory muscle fatigue, leading to eventual failure and arrest.

Choice B rationale

Bradypnea, an abnormally slow respiratory rate for the child's age, is an ominous sign in pediatric respiratory distress. It often follows a period of tachypnea and hyperventilation, indicating profound respiratory muscle fatigue and exhaustion. This decrease in effort leads to rapid hypercapnia and uncompensated respiratory acidosis, preceding arrest.

Choice C rationale

Central cyanosis, a bluish discoloration of the mucous membranes and trunk, is a late and critical sign indicating severe hypoxemia, with a significant absolute amount of deoxyhemoglobin in the arterial blood (typically >5 g/dL). This signals inadequate oxygen delivery to the vital organs, often directly preceding cardiac and respiratory failure.

Choice D rationale

Gasping or agonal breathing represents a primitive brainstem reflex that occurs when the respiratory drive center is severely compromised due to profound cerebral hypoxia or ischemia. These are infrequent, deep, reflexive breaths, often ineffective for gas exchange, and are a terminal event immediately preceding complete respiratory cessation.

Choice E rationale

While tachycardia (elevated heart rate, normal range varies by age, e.g., >100-110 bpm in a school-aged child) is a common early compensatory mechanism in respiratory distress to improve cardiac output and oxygen delivery, it is not a sign of impending arrest. Bradycardia, caused by severe hypoxemia and acidosis depressing myocardial function, is the more critical pre-arrest sign.

Choice A rationale

The expected urine output for an infant is 1-2 mL/kg/hr. For this 7.5 kg infant, the minimum expected output is (1 mL/kg/hr× 7.5 kg) × 12 hours = 90 mL. The actual output of 93 mL over 12 hours is just above the minimum of 90 mL, placing it within the normal, expected physiological range.

Choice B rationale

This choice is incorrect because the calculated minimum normal urine output for a 7.5 kg infant over 12 hours is 90 mL. The actual output of 93 mL exceeds this minimum threshold, confirming that the infant's renal excretion is adequate and within the lower bounds of the normal physiological range.