A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.

Rationale for correct choices:

• Reye’s syndrome is a rare but serious condition that can develop after a viral illness when aspirin is given to children. The toddler’s symptoms—lethargy, persistent vomiting, and difficulty rousing—align with signs of increased intracranial pressure associated with Reye’s syndrome.

• Aspirin administration during a recent influenza A infection is a known trigger for Reye’s syndrome, as it can cause acute encephalopathy and liver dysfunction in pediatric patients.

Rationale for incorrect choices:

• Bronchitis would present with prominent lower respiratory symptoms such as productive cough, wheezing, and abnormal lung sounds, which are not noted here.

• Gastroenteritis is characterized by vomiting and diarrhea with signs of dehydration; this child has no diarrhea, and the neurological decline suggests CNS involvement rather than a purely GI process.

• Acetaminophen administration is not linked to Reye’s syndrome; toxicity causes liver injury but does not present with acute encephalopathy following viral illness in the same way.

• Cough finding is unrelated to the primary cause of the neurological changes and persistent vomiting; the cough has been present but is not the trigger for the current complication.