Continue respiratory assessment.
The nurse should complete the respiratory assessment, as this will provide important baseline information for the healthcare provider (HCP).
question
Which techniques should the nurse use to assess for respiratory distress?
answer
Place a pulse oximeter on a big toe of the baby's foot.
The nurse should use a pulse oximeter to measure the infant's oxygen saturation level. A decreased oxygen saturation level is a sign of respiratory compromise. The foot is the preferred site for a pulse oximeter because infants are apt to scratch themselves with the probe if it is placed on the hand. Fingers are not used because they are too small to support the probe. The infant's foot should be kept warm, with a sock if necessary, to ensure accurate measurement.
Inspect the chest wall for symmetry and retractions.
Respiratory distress can be seen as an asymmetrical chest wall expansion, intercostal retractions, and nasal flaring.
Count the infant's pulse and respiratory rates.
Tachycardia and tachypnea can both be signs of respiratory distress.
question
The nurse continues the assessment. Which assessment finding exhibited by Emma warrants immediate intervention by the nurse?
answer
minimal response to stimuli
- A change in the infant's level of consciousness is a significant indicator of poor oxygenation and requires immediate intervention by the nurse.
question
A nursing student is precepting with Emma's primary nurse. The nurse asks the student about signs and symptoms of respiratory distress. Which findings should the nurse confirm is a sign of worsening shortness of breath for the client?
answer
Nasal flaring.
Nasal flaring is sign of respiratory distress in the pediatric client.
Restlessness.
Restlessness is an early sign of respiratory distress in the pediatric client.
Retractions.
This is a sign of respiratory distress in the pediatric client.
question
Emma is having some increasing respiratory distress. The nurse notes that Emma is nasal flaring and she is having substernal retractions. The nurse suctions her mouth and nasal passages with a bulb syringe to clear secretions and emergency blow-by oxygen is given. Emma is now responding to Susan's voice. Susan attempts to bottle feed Emma. The nurse observes that the infant has difficulty sucking and keeps spitting out the nipple. The nurse notes that Emma still has thick nasal secretions and that her respiratory rate has increased to 50 breaths per minute with her sucking effort.
Which action should the nurse take?
answer
Suction the infant's nose again.
Due to the posterior soft palate covering the oropharynx and the tongue's close proximity with the hard and soft palate, infants this age are obligate nose breathers. When the nose is congested they cannot form a seal to suck. Consequently, their respiratory effort increases as they attempt to breathe through congested nasal passages and suck at the same time.
question
Soon after, the HCP evaluates Emma and determines that she has respiratory syncytial virus (RSV) prescribes the following: NPO status, IV fluids, Ventolin (albuterol) aerosol, diphenhydramine (Benadryl) 0.5 mg/kg every 8 hours PO, oxygen set to 1/2 liter per nasal cannula, and nasal suction with normal saline prn.
Additionally, the HCP prescribes 5% dextrose and one-half normal saline with 20 mEq potassium chloride at 100 mL per kg over 24 hrs. Emma weighs 12 pounds.
answer
23
Convert weight in pounds to kilograms and multiple by 100 mL; then divide by 24 hours for hourly flow rate. 12 lbs /2.2 kg = 5.45 kg × 100 mL ÷ 24 hours = 22.7 mL/hour. 23 mL per hour is acceptable.
question
After the client has had many unsuccessful IV attempts, the IV therapy team is called, and they decide to start the IV in the infant's scalp. What should the nurse do next to best promote atraumatic care and to get the IV in place in a timely fashion?
answer
Give the infant sucrose solution (Sweet Ease) on a nipple to suck during the procedure.
It has been shown that an infant sucking during painful, invasive procedures reduces pain. The use of a sucrose solution (Sweet Ease) also reduces the painful experience for the infant and is the most atraumatic intervention.
question
The IV line is placed successfully in a peripheral vein in the right lateral side of the scalp and secured with a tegaderm adhesive and tape. The nurse assesses that the IV flushes well and is patent. Which would the nurse expect to see if the IV infiltrated? (Select all the apply.)
answer
Swelling.
Swelling will be noted with an infiltrated IV.
Pain.
Pain may be seen when the IV has infiltrated.
Redness.
Erythema is noted around an infiltrated IV.
question
The pulse oximeter begins to ding and the nurse notices that Emma's oxygen saturation level on room air is 90%. Which action should the nurse take?
answer
Apply O2 at ½ liter by nasal cannula as prescribed.
After applying the nasal cannula, the nurse should monitor the infant for a positive respiratory response. If the infant's oxygen level does not improve to 94% or greater within 15 minutes, the HCP should be notified.
question
The nurse reviews Emma's medication prescriptions. Which medication should the nurse question prior to administration?
answer
Oral Prednisone.
Corticosteroids are not indicated for a client who has bronchiolitis. The appropriate use of corticosteroids remains controversial.
question
After clarifying the prescriptions and stabilizing the infant's oxygen saturation level to 94%, the nurse prepares to transport the infant to the pediatric unit. Which nursing diagnosis has the highest priority for Emma?
answer
Ineffective airway clearance.
The pathophysiology of RSV includes edema of the bronchioles and thick secretions that can block the airways, causing obstruction and hyperinflation. Because these factors can lead to increased respiratory effort and possibly respiratory failure, this diagnosis has the highest priority.
question
Emma is tachypneic and is on oxygen at ½ L/minute via nasal cannula. The HCP also prescribes cardiac telemetry to start upon Emma's arrival at the pediatric medical unit.
Which staff member should be assigned to transport Emma to the pediatric unit?
answer
An experienced pediatric registered nurse (RN) floated to the ED for the day.
The experienced pediatric nurse who has knowledge of the care of children with respiratory illness is the staff member that should be assigned to transport a sick infant.
question
While Emma is being prepared for transfer, the ED nurse calls the medical unit and gives report to the charge nurse. The charge nurse reviews the current staff assignments to determine who should be assigned the care of the infant.
Which staff member should the charge nurse assign to care for Emma?
answer
An RN caring for a 9-month-old with pneumonia.
The RN has the expertise needed to make the frequent assessments that are required. In addition, assigning children with similar diagnoses to the same nurse is most appropriate.
question
The infant and her mother are escorted to the medical pediatric unit. Susan states, "I cannot believe this is happening. I feel like the worst mother in the world. Is there anything that I can do to help my child?"
Which statement by the nurse reflects the philosophy of family-centered care?
answer
While you hold Emma, we can talk about her diagnosis and care."
Discussing Emma's diagnosis and plan of care enables the mother to be a part of the care-giving process. Encouraging the mother to hold the infant furthers the mother's participation in her infant's care. These are all part of the philosophy of family-centered care.
question
Later in the day, the nurse hears the infant's alarm go off and goes to the child's room. She assesses the infant who is grunting and has nasal flaring and retractions. The infant's respirations are at 62, and her pulse oxygen level is 82%.
Which action should the nurse take?
answer
Reposition the infant in an elevated position.
Repositioning the infant in an elevated position with the head of the bed to 40 degrees allows for better expansion of the lung fields and improved oxygenation.
Notify the HCP.
The HCP should be informed that the child is experiencing increased respiratory distress so that the HCP can give to direct further orders.
Activate the hospital rapid response team to come to the bedside.
The child is exhibiting signs of severe respiratory compromise. The rapid response team should be notified and available to assist with this child to stabilize the airway and to prevent a full blown code.
question
The nurse understands which are considered late signs of respiratory distress?
answer
Peripheral cyanosis.
This is a late sign of respiratory distress.
Bradypnea.
This is a late sign of respiratory distress.
Stupor.
This is a late sign of respiratory distress.
question
Emma's condition does not improve and begins to decline. The HCP arranges for the infant to be transferred to the pediatric intensive care unit (PICU). After assessing the infant, the HCP decides to administer ribavirin (Virazole) by aerosol.
Which precautions should the PICU nurse initiate while Emma is receiving this medication?
answer
Restrict pregnant caregivers.
Ribavirin (Virazole) is known to be teratogenic in animals and potentially harmful to the human fetus. Pregnant caregivers should be excluded from contact with this infant while the infant is being treated with ribavirin (Virazole).
question
Emma is placed in a mist tent that will deliver the ribavirin (Virazole) over an 18-hour period during the day. Susan asks the nurse if Emma could have any type of toy or activity so that she will not feel alone while she is in the tent by herself.
What type of toy should the nurse recommend?
answer
A musical mobile.
Infants in this age group love to look at mobiles and hear music. A crib toy that can be washed, such as a mobile, is a good choice.
question
Three days later, Emma's condition improves, and she is transferred back to the pediatric unit. Emma is scheduled for discharge in 2 days if she remains stable. Susan is anxious to learn how to care for Emma at home. The nurse begins by teaching the mother about nasal suctioning because the symptoms of cough and nasal congestion will persist for up to 2 weeks after the acute phase of the illness.After gathering exam gloves and a bulb syringe, the nurse should include what other equipment when gathering supplies to teach the mother how to perform nasal suction?
answer
Nasal saline drops.
Saline is used to loosen secretions prior to suction.
question
The nurse completes the initial demonstration, and Susan performs a successful return demonstration. Susan asks the nurse, "What if I can't remove any mucous when I suction Emma's nose?" How should the nurse respond?
answer
"The amount of mucous is less important than Emma's behavior after the treatment."
If Emma is able to breathe more easily and is able to feed successfully, the amount of mucous removed is immaterial.
question
Susan says that she feels comfortable with the suctioning procedure. Two days later, Emma is ready for discharge in the morning. Susan states that she is fearful Emma may become ill again and asks the nurse what she can do to help prevent that from happening. How should the nurse respond?
answer
Use of proper hand hygiene and avoiding contact with the sick can reduce the risk of infections."
The CDC has indicated that hand washing is one of the most effective measures for protection from illness. Staying away from persons known to be ill also reduces that risk.
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