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.

Answer and Explanation

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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Correct Answer is D

Explanation

The first intervention the PN should implement is to **sit and oﬀer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Oﬀering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.

A. Support the client's upper body and knees with pillows. B. Encourage the client to push with the next contraction. C. Assist the team to prepare for a possible cesarean delivery. D. Gently wrap the cord with a dry sterile dressing.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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