A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?

Diaphragmatic respirations.

Bilateral bronchial breath sounds.

Flaring of the nares.

A resting respiratory rate of 35 breaths/minute.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.

Choice B rationale

Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.

Choice C rationale

Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.

Choice D rationale

A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .

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Correct Answer is B

Explanation

Choice A rationale

Telling the child that you're glad the mother explained the procedure doesn't provide the child with an opportunity to express their understanding or concerns. It is important to engage the child directly to understand what they know and how they feel about the operation, rather than relying solely on what the parent has communicated.

Choice B rationale

Asking the child to explain what an operation is allows the nurse to gauge the child's understanding and provides an opportunity to correct any misconceptions. This approach also encourages open communication and helps the child feel more involved and informed about their own care, which can reduce anxiety.

Choice C rationale

Reassuring the child that the hospital staff will take very good care of them is comforting, but it doesn't address the child's need for information and understanding about the operation. While it's important to provide reassurance, the primary focus should be on ensuring the child comprehends what will happen.

Choice D rationale

Directly asking the child if they are scared might lead to a yes or no answer, and doesn't necessarily encourage them to share their specific fears or concerns. It is more effective to ask open-ended questions that allow the child to express their feelings in more detail, which can then be addressed by the nurse.

A. Maternal blood pressure. B. Level of pain sensation. C. Station of presenting part. D. Variability of fetal heart rate.

Correct Answer is A

Explanation

Choice A rationale

Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.

Choice B rationale

Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.

Choice C rationale

The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.

Choice D rationale

Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .

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A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

Explanation

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A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?