A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night.
Which finding is most significant in planning care for this family?
The mother states the baby is irritable during feedings.
The mother is a single parent and lives with her parents.
The infant's formula has been changed twice.
The diaper area shows severe skin breakdown.
The Correct Answer is D
The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Correct Answer is B
Explanation
Albuterol is a beta-adrenergic agonist agent that is used to open the airways in people with bronchial asthma. The mother's use of this medication to open her son's airway when he is having trouble breathing is appropriate. Overuse of the drug may cause side effects, but it does not cause chronic bronchitis (A)
Albuterol helps to relax the muscles in the airways, but it does not reduce airway inflammation (C)There is no indication that the child needs immediate evaluation (D)
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