A nurse is assessing a 6-month-old infant who has respiratory syncytial virus.
The nurse should immediately report which of the following findings to the provider?
Cough or difficulty in breathing.
Oxygen saturation < 90% or central cyanosis.
Severe respiratory distress (e.g grunting, very severe chest indrawing).
Signs of pneumonia with a general danger.
The Correct Answer is B
This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This helps to keep the urine collection bag in place while the infant is active.
Choice A is wrong because the opening of the bag should be positioned over the urethra only, not over both the urethra and anus.
Choice C is wrong because there is no need to apply lidocaine gel to the perineum before attaching the bag.
Choice D is wrong because there is no need to stretch the perineum taut when applying the bag.
Correct Answer is A
Explanation
A 24-gauge catheter is the smallest-gauge catheter and is appropriate for administering IV fluids and medications to an infant.
Choice B is wrong because an opaque dressing would prevent the nurse from visualizing the insertion site.
Choice C is wrong because starting an IV in an infant’s foot can be painful and difficult to secure.
Choice D is wrong because IV sites should be changed every 72-96 hours or according to facility policy.
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