A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and
intercostal retractions. The nurse's next action should be to:
a.
Assure the mother that these signs are normal symptoms of a cold.
b.
Recognize that these are serious signs, and contact the physician.
c.
Ask the mother if the infant has had trouble with feedings.
d.
Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.
ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time.
You might also like to view...
A 71-year-old patient with a history of depression will be receiving vecuronium to prevent trauma during electroconvulsive therapy. Prior to the procedure, the care team must assess the patient's
A) understanding of the pharmacodynamics of vecuronium. B) goals for recovery. C) renal and hepatic status. D) blood glucose levels
The nurse receives a referral to visit a client who neighbors fear is being abused by a spouse. The client allows the nurse inside but is obviously reluctant to have the nurse in the home. The nurse could best address the client's concerns by:
(Select all that apply.) 1. Tactfully communicating the reason for the visit. 2. Establishing appropriate expectations for the visit for the client and nurse. 3. Starting to establish a rapport with the client. 4. Stating that the neighbors made the referral. 5. Informing the client that her name has been given to a local women's shelter.
The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?
1. Mean arterial pressure reaches 60. 2. Mean arterial pressure reaches 90. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour.
If a patient on a hypothermia blanket starts to shiver, what action should the nurse take?
a. Discontinue treatment. b. Place more padding around the patient. c. Discuss with the physician the use of a metabolic stimulant. d. Increase the temperature to a more comfortable range.