A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?
Flaring of the nares.
Resting respiratory rate of 35 breaths/minute.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
The Correct Answer is A
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The first action the PN should take is to check the client's serum human chorionic gonadotropin (hCG) level. This hormone is produced by the placenta and can provide important information about the viability of the pregnancy.
Option B, verifying the date of the last menstrual cycle, can provide useful information about the gestational age of the pregnancy but is not the first priority.
Option C, repeating a urine pregnancy test, can confirm the presence of a pregnancy but does not provide information about its viability.
Option D, inquiring about the last occurrence of intercourse, is not relevant to addressing the client's immediate concern of vaginal bleeding.
Correct Answer is C
Explanation
The umbilical cord prolapse is an emergency situation that requires immediate intervention. The PN should not attempt to push the cord back into the vagina or cover it with a dry sterile dressing. Instead, the PN should notify the healthcare provider and the obstetrical team and assist in preparing for an emergency cesarean delivery.
Option A and B may be appropriate in some situations, but they are not the priority in this scenario.
Therefore, options A, B, and D are not answers because they do not address the immediate emergency of umbilical cord prolapse.
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