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 A
Explanation
Oral sucrose solution has been shown to have analgesic effects and can help reduce pain and discomfort in infants during procedures such as immunizations.
Choice B is wrong because Use a 20-gauge needle for the injections is not an answer because a 20-gauge needle is larger than the recommended size for infant immunizations.
Choice C is wrong because Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not an answer because EMLA cream needs to be applied at least 1 hour before the procedure to be effective.
Choice D is wrong because Inject the immunizations into the deltoid muscle is not an answer because the deltoid muscle is not recommended for infants under 12 months of age.
Correct Answer is ["A","B","D"]
Explanation
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
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