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
Following the child’s home sleep routine can help reduce anxiety and promote adequate sleep.
Children thrive on routine and consistency, and maintaining their usual sleep routine can provide a sense of familiarity and comfort in an unfamiliar environment.
Choice B is wrong because leaving the lights on can disrupt the child’s sleep.
Choice C is wrong because allowing the child to adjust their bedtime may disrupt their sleep routine and lead to inadequate sleep.
Choice D is a good option, but following the child’s home sleep routine is the best way to promote adequate sleep.
Correct Answer is D
Explanation
The nurse should plan to administer the human papillomavirus (HPV) vaccine to the 12-year-old client.
The Centers for Disease Control and Prevention (CDC) recommends that children aged 11-12 years old receive two doses of the HPV vaccine separated by 6-12 months.
Choice A is wrong because Hepatitis A vaccine is typically given to children at age.
Choice B is wrong because Varicella vaccine is typically given to children at ages 12-15 months and 4-6 years.
Choice C is wrong because DTaP vaccine is typically given to children at ages 2, 4, and 6 months, and between ages 15-18 months and 4-6 years.
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