A nurse is assisting in the care of an 8-month-old infant in the emergency department (ED).
Select the 3 priority actions the nurse should take.
Apply continuous pulse oximeter.
Reinforce instructions for parent regarding use of breast pump to express milk.
Administer acetaminophen.
Assist with insertion of peripheral intravenous access device.
Suction the nares.
Apply urine collection bag.
Obtain blood cultures.
Correct Answer : A,D,E
A. Apply continuous pulse oximeter: The infant’s oxygen saturation has declined from 94% to 92% with increasing respiratory distress and tachypnea, indicating worsening gas exchange. Continuous pulse oximetry is essential to monitor for hypoxemia in bronchiolitis, where airway inflammation and mucus plugging impair ventilation. Early detection of desaturation allows prompt oxygen administration to prevent respiratory failure.
B. Reinforce instructions for parent regarding use of breast pump to express milk: Although maintaining nutrition is important, the infant’s respiratory rate has increased to 70/min, and oral intake is restricted when the rate exceeds 60/min due to aspiration risk. Education about breast pumping does not address the immediate priority of airway and breathing compromise.
C. Administer acetaminophen: The infant has a temperature of 38.7°C, which meets criteria for antipyretic administration. However, fever management is secondary to stabilizing airway and breathing in a child showing escalating respiratory distress and declining oxygen saturation.
D. Assist with insertion of peripheral intravenous access device: The infant demonstrates poor breastfeeding, tachypnea, and signs of mild dehydration, increasing the risk of fluid deficit. IV access is necessary to initiate the prescribed maintenance fluids and maintain hydration when oral intake is unsafe. Establishing vascular access also prepares for potential rapid deterioration.
E. Suction the nares: Thick nasal secretions contribute to airway obstruction, especially in infants who are obligate nose breathers. Suctioning the nares reduces upper airway resistance, improves airflow, and may decrease work of breathing. Clearing secretions directly addresses the immediate respiratory compromise seen in bronchiolitis.
F. Apply urine collection bag: A urine specimen for culture is ordered, but obtaining it does not take priority over airway stabilization and oxygenation. While monitoring output is important for hydration status, it is not the most urgent intervention given the infant’s respiratory deterioration.
G. Obtain blood cultures: Blood cultures are indicated to evaluate for possible bacterial infection; however, they are not the immediate priority in a child with worsening respiratory distress. Stabilizing airway, breathing, and circulation takes precedence before diagnostic specimen collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will have general anesthesia during the procedure.": Thoracentesis is performed using local anesthesia to numb the puncture site, not general anesthesia. Local anesthesia allows the client to remain awake, follow breathing instructions, and reduce procedural risk associated with systemic sedation. General anesthesia is unnecessary and increases potential complications.
B. "I will lie flat for 6 hours following the procedure.": After a thoracentesis, clients are generally encouraged to resume normal positioning as tolerated, often sitting upright or semi-Fowler’s position. Prolonged flat positioning is not required and does not prevent complications. Monitoring focuses on respiratory status and observing for pneumothorax.
C. "I will have a chest x-ray following the procedure.": A post-procedure chest x-ray is standard to confirm lung re-expansion and to check for complications such as pneumothorax or hemothorax. This imaging ensures that the lung has not been punctured or collapsed during fluid removal, and it guides further management if abnormalities are detected.
D. "I will breathe deeply through my nose during the procedure.": Clients are usually instructed to sit upright and remain still, with occasional breath-holding at end-inspiration during needle insertion. Breathing deeply through the nose is not a standard instruction and may increase movement, risking needle trauma to lung tissue.
Correct Answer is C
Explanation
A. Turn the newborn's head quickly to one side while they are sleeping: Turning the head quickly elicits the tonic neck reflex (also called the “fencing reflex”), not the Moro reflex. This reflex causes the newborn to extend the arm and leg on the side the head is turned while flexing the opposite limbs.
B. Place a finger in the newborn's palm: Placing a finger in the newborn’s palm elicits the palmar grasp reflex, causing the infant to curl their fingers around the object. It does not trigger the Moro reflex, which involves a startle response of the whole body.
C. Clap hands after laying the newborn on a flat surface: The Moro reflex is elicited by a sudden loss of support or a startle stimulus, such as a loud clap or gentle dropping of the infant’s head slightly backward while lying on a flat surface. The newborn responds with abduction and extension of the arms, followed by adduction and often crying.
D. Hold the newborn upright with one foot touching the crib surface: This action is used to elicit the stepping or walking reflex, in which the newborn makes stepping movements. It does not elicit the Moro reflex, which is a response to sudden displacement or loud stimuli.
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