A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)

Warm extremities

Wheezing

Nasal flaring

Retraction of sternal muscles

Oxygen saturation 95%

Answer and Explanation

Correct Answer : B,C,D

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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Correct Answer is A

Explanation

A. This option is the most appropriate choice for an infant with respiratory syncytial virus (RSV). RSV is highly contagious and primarily spreads through respiratory secretions. Placing the infant in a private room helps to minimize the risk of transmission to other patients. Contact and droplet precautions should be implemented to further prevent the spread of the virus.

B. This choice is not ideal because both RSV and croup are respiratory infections that can spread easily among infants. Placing an infant with RSV in a semi-private room with another infant increases the risk of transmission of both infections to each other.

C. While isolating the infant in a private room is appropriate for preventing the spread of RSV, the term "protective isolation" typically refers to a type of isolation used for patients who have compromised immune systems.

D. Placing the infant with RSV in a semi-private room with a toddler who has pneumonia is not recommended. Both RSV and pneumonia are respiratory infections that can spread easily among patients, especially infants and young children who are more susceptible to complications.

A. Constipation B. Depressed anterior fontanel C. Presence of the rooting reflex D. High-pitched cry

Correct Answer is D

Explanation

D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.

A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.

B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.

C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

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A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)