A nurse is caring for a 4-month-old infant in the outpatient setting.
Which of the following should the nurse identify as unexpected findings? Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
|
Body system |
Findings |
|
Vital Signs |
Temperature 36.9°C (98.4° F) Heart rate 162/min Respiratory rate 28/min Oxygen saturation 97% on room air |
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Gastrointestinal |
Also spits up after every feeding, sometimes forcefully. Infant is formula fed and recently began refusing some feedings. Bowel sounds normoactive. Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus. Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz). |
Temperature 36.9°C (98.4° F)
Heart rate 162/min
Respiratory rate 28/min
Also spits up after every feeding, sometimes forcefully
Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus
Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz)
The Correct Answer is ["B","D","E"]
Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.
Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.
Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.
Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.
Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.
Correct Answer is []
Explanation
Condition Most Likely Experiencing: Bronchiolitis
The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.
Actions to Take:
- Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
- Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.
Parameters to Monitor:
- Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
- Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.
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