A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

A. Avoid eye contact with the client: Avoiding eye contact can convey disinterest or disengagement, which may increase the client’s sense of isolation. Therapeutic engagement requires maintaining appropriate eye contact to promote trust and effective communication.

B. Encourage the client to lie down in a quiet room: Isolating the client in a quiet room may intensify auditory hallucinations, as there are fewer environmental stimuli to help the client reality-test. Structured interaction and distraction techniques are generally more effective.

C. Ask the client directly what they are hearing: Engaging the client in a nonjudgmental discussion about their hallucinations helps the nurse understand the content, assess risk, and provide support. This approach promotes reality orientation, therapeutic rapport, and early identification of command hallucinations that may pose safety risks.

D. Refer to the hallucinations as if they are real: Validating hallucinations as real can reinforce psychotic thinking and perpetuate the hallucinations. The nurse should acknowledge the client’s experience without confirming the reality of the voices.

Rationale:

• Hypoxia: Hypoxia occurs in both epiglottitis and RSV due to airway obstruction or lower respiratory involvement. In epiglottitis, airway swelling can limit oxygen intake, whereas in RSV, lower airway inflammation and bronchiolitis cause oxygen desaturation. Streptococcal pharyngitis typically does not impair oxygenation.

• Fever: Fever is a nonspecific finding seen in epiglottitis, RSV, and streptococcal pharyngitis. Infection-induced inflammation and immune response in all three conditions cause elevated temperatures. The degree and onset of fever can vary among the conditions.

• Tachypnea: Tachypnea is a compensatory response to hypoxia and airway compromise. It is commonly observed in epiglottitis due to upper airway obstruction and in RSV due to bronchiolar inflammation. It is usually absent in isolated streptococcal pharyngitis.

• Drooling: Drooling is a hallmark sign of epiglottitis due to painful swallowing and airway obstruction. It is not typical in RSV or streptococcal pharyngitis. Presence of drooling indicates urgent airway assessment.

• Exudate on pharynx: Exudative pharyngitis is characteristic of streptococcal infections. It is rarely seen in epiglottitis and RSV. White or yellow exudates on the tonsils help differentiate bacterial pharyngitis from viral or upper airway conditions.

• Wheezing upon auscultation: Wheezing is associated with lower airway involvement, commonly seen in RSV bronchiolitis. It is not typically present in epiglottitis or streptococcal pharyngitis. Wheezing reflects bronchospasm or airway inflammation.