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Which breath sounds indicate the infant is experiencing respiratory distress? (Select All That Apply: SATA)

Eupnea

Apnea

Tachypnea

Wheezing

Grunting

Retractions

Answer and Explanation

Correct Answer : B,C,D,E,F

a) Eupnea: Normal breathing rate and pattern, not indicative of distress.

b) Apnea: Cessation of breathing, a sign of significant distress.

c) Tachypnea: Rapid breathing, often seen in respiratory distress.

d) Wheezing: High-pitched, musical sounds during expiration, suggesting airway obstruction.

e) Grunting: Heard during expiration, a sign of the body's attempt to keep air in the lungs, indicating distress.

f) Retractions: Visible sinking of tissues between ribs or at the sternum, indicating increased effort to breathe, a sign of distress.

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Correct Answer is B

Explanation

a) Ineffective tissue perfusion: Though this might be a concern, the highest priority for an HIV-positive child is the risk of acquiring infections due to compromised immunity.

b) Risk for infection: HIV weakens the immune system, significantly increasing the risk of contracting infections. Preventing infections is the primary focus.

c) Risk for fluid volume deficit: While important, it's not the highest priority compared to the risk of infection due to HIV.

d) Ineffective thermoregulation: Not typically the primary concern for an HIV-positive child compared to the increased risk of infections due to the compromised immune system.

A. A large bore needle with Heimlich valve for needle aspiration B. A chest tube set up C. Intubation setup D. Appropriate self-inflating bag and correct mask size

Correct Answer is C

Explanation

a) A large bore needle with Heimlich valve for needle aspiration: Not typically used in the management of diaphragmatic hernia.

b) A chest tube set up: While useful in other situations, it may not be the immediate priority in managing diaphragmatic hernia.

c) Intubation setup: Essential for respiratory support in newborns with diaphragmatic hernia, as it helps manage respiratory distress.

d) Appropriate self-inflating bag and correct mask size: Important for neonatal resuscitation but doesn’t specifically address the respiratory challenges associated with diaphragmatic hernia.

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Which breath sounds indicate the infant is experiencing respiratory distress? (Select All That Apply: SATA)

Nursing Test Bank

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