Which is the most appropriate action for the nurse to take when sternal and intercostal retractions are noted in an infant?
A) Nothing, as this finding is normal in infants.
B) Notify the physician or provider immediately.
C) Assess the infant again in 15 minutes.
D) Increase fluid intake.
B) Notify the physician or provider immediately.
Explanation: A) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action.
B) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action.
C) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action.
D) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action.
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