When performing a physical assessment on an infant, the nurse understands that which of the following techniques will aid in the ability to complete the examination? (Select all that apply)

Choice A rationale

While it’s true that early recognition of symptoms can help in managing respiratory infections, this is not the primary reason why infants are at increased risk. Infants can be more susceptible to respiratory infections due to physiological factors rather than caregiver awareness.

Choice B rationale

Infants do have smaller airways compared to adults, which can allow for a larger number of organisms to enter. However, the size of the airways is not the main factor that increases the risk of respiratory infections in infants. Other factors, such as the maturity of the immune system and the ability to clear the airways, play a more significant role.

Choice C rationale

Infants’ airways are indeed narrow and can obstruct more easily, trapping organisms. This is one of the main reasons why infants are at an increased risk for respiratory infections. The narrow airways in infants can lead to increased resistance and decreased airflow, making it easier for organisms to invade and cause infections.

Choice D rationale

While it’s true that infants have faster respiratory rates than adults, this does not necessarily increase their risk for respiratory infections. A faster respiratory rate does not inhibit an infant’s ability to cough effectively. In fact, coughing is a protective reflex that can help clear the airways of mucus and foreign particles.

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.