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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The infant's symptoms are consistent with postoperative pain, which can be expected following a surgical procedure like pyloromyotomy. The PN should administer the prescribed analgesic medication to relieve the infant's discomfort and pain. It is crucial to manage pain appropriately in infants to promote healing, improve feeding tolerance, and prevent complications.
Option A is not appropriate as the infant's symptoms are not indicative of hypoglycemia.
Option C is not appropriate as the infant's symptoms do not indicate hypothermia.
Option D is not appropriate as the infant's symptoms do not indicate dehydration.
Correct Answer is D
Explanation
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
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