A nurse is caring for a newborn who has hydrocephalus.
Which of the following manifestations should the nurse expect to find?

Choice A rationale:

Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.

Choice B rationale:

Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.

Choice C rationale:

Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 88% on room air to 94% on 2 L/min O2) indicates that the treatment plan is effective in improving the child’s oxygenation.

Choice D rationale:

Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 40 breaths/min to 32 breaths/min) indicates that the treatment plan is effective in reducing the child’s respiratory distress.

Choice E rationale:

Pulse rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in pulse rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

Choice F rationale:

Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of mild bilateral expiratory wheezes and diminished breath sounds in the bases indicates some improvement compared to the initial assessment.

Choice G rationale:

Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.

The correct answer is Choice A.

Choice A rationale

A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.

Choice B rationale

While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.

Choice C rationale

The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.

Choice D rationale

The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .