A toddler is brought to the clinic with a low-grade fever and the mother describes a grunting sound made by the child on expiration. The respiratory rate is 24 breaths/minute. What action by the nurse is most appropriate?

Question

A.
Assess nose and throat for foreign bodies.
B.
Facilitate a stat chest x-ray.
C.
Obtain an oxygen saturation; notify provider.
D.
Weigh and measure child then calculate BMI.

Answer 1

ANS: C
Grunting noises are heard at the end of expiration and are caused by glottal closing. They can be indicative of respiratory distress or pneumonia. This child's respiratory rate is normal for age. The nurse should perform further assessments and notify the provider. Grunting is not associated with foreign bodies. The child is stable and does not need a stat chest x-ray, although he or she probably will have one after being seen. The BMI might be important for a child who snores or breathes noisily because snoring is often associated with obesity (along with foreign body, nasal polyps, choanal obstruction, or hypertrophied adenoid tissue).