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 C
Explanation
Pad the side rails of the crib.
Padding the side rails of the crib can help prevent injury if the infant experiences seizures, which can be a symptom of bacterial meningitis.
Choice A is wrong because infants with bacterial meningitis may be sensitive to noise and light, so keeping the television on may not be appropriate.
Choice B is wrong because range of motion exercises to the neck and shoulders may not be appropriate for an infant with bacterial meningitis.
Choice D is wrong because placing the infant in a semiprivate room may increase the risk of infection 1.
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