A nurse is reviewing the laboratory test results for a 3-year-old child who has been diagnosed with RSV infection.
The nurse notes that the child’s respiratory rate is 35 breaths per minute, oxygen saturation is 96%, pH is 7.38, and PaCO2 is 40.
Which of the following actions should the nurse take based on these results? (Select all that apply).

Choice A rationale:

RSV (Respiratory Syncytial Virus) primarily affects young children and infants, making them more vulnerable to severe complications.

Adults can also contract the virus, but it is most common and dangerous in children under one year old.

Therefore, stating that RSV is most common in adults is incorrect.

Choice B rationale:

RSV is most common in children under one year old, so your grandchildren could be at risk.

This statement is correct.

RSV is highly contagious and spreads through respiratory droplets.

Infants and young children are more prone to severe infections due to their underdeveloped immune systems.

Hence, the nurse should educate the client that their grandchildren, especially those under one year old, are at risk of contracting RSV.

Choice C rationale:

RSV does affect individuals with compromised immune systems, but it is not limited to them.

Children, especially those under one year old, are also highly susceptible to RSV infections.

Therefore, this statement is not comprehensive and accurate.

Choice D rationale:

RSV can be transmitted from person to person through respiratory secretions.

It is highly contagious, especially in crowded places like daycare centers and hospitals.

This statement is incorrect, as RSV transmission is well-documented.

Choice A rationale:

Administering bronchodilators as prescribed is appropriate for managing severe respiratory distress and wheezing in children with RSV infection.

Bronchodilators help dilate the airways, making it easier for the child to breathe.

This intervention addresses one of the specific symptoms mentioned in the scenario.

Choice B rationale:

Encouraging fluid intake is important to prevent dehydration, especially in children with respiratory infections.

It helps maintain hydration status, which is essential for overall health.

While important, this choice alone does not address the severe respiratory distress symptoms mentioned in the scenario.

Choice C rationale:

Monitoring oxygen saturation levels is crucial in children with RSV infection, especially when they exhibit symptoms of severe respiratory distress such as wheezing, retractions, nasal flaring, tachypnea, and cyanosis.

Monitoring oxygen saturation helps assess the child's oxygenation status and guides interventions such as oxygen therapy.

Choice D rationale:

The correct answer is choice D, “All of these.”.

This is because all the interventions mentioned in choices A, B, and C are appropriate and necessary for managing severe respiratory distress in a toddler with RSV infection.

Administering bronchodilators addresses airway constriction and wheezing, encouraging fluid intake prevents dehydration, and monitoring oxygen saturation levels ensures appropriate oxygenation, allowing comprehensive care for the child’s condition.