CH 40 Nursing Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder

A community health nurse is conducting a parenting class on respiratory syncytial virus (RSV). What statement made by a parent indicates that the teaching has been successful? "RSV season occurs primarily April through September." "Exposure to second- or thirdhand smoke increases the risk for developing RSV." "Infants are less affected by RSV than older children." "Early initiation of antibiotics can lessen the severity of the infection."

"Exposure to second- or thirdhand smoke increases the risk for developing RSV."

Adult oxygen consumption is 3 to 4 L/min, while infants consume

6 to 8 L/min.

Infant vital signs

Pulse = 85 to 205 BP = 85 to 104 systolic Respiratory rate = 30 to 60

Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child? Vomiting Fever Diarrhea Nasal congestion

Nasal Congestion Nasal Passages are smaller meaning that even a small amount of mucous can cause an obstruction

Rales

Crackles; wet crackling noise in lungs

The nurse caring for the child with asthma weighs the child daily. What is the most important reason for doing a daily weight on this child? To monitor the child's growth pattern To determine medication dosages To determine fluid losses To ensure that the child's food intake is adequate

to determine fluid loss

A 3-year-old child with asthma and a respiratory tract infection is prescribed an antibiotic and a bronchodilator. The nurse notes the following during assessment: oral temperature 100.2°F (37.9°C), respirations 52 breaths/minute, heart rate 90 beats/minute, O2 saturation 95% on room air. Which action will the nurse take first? Apply a cardiac monitor to the child. Administer the bronchodilator via a nebulizer. Give the antibiotic as prescribed. Apply oxygen at 2 liters via a nasal cannula.

Administer the bronchodilator via a nebulizer.

The nurse is caring for a child with thickened pulmonary secretions. Which action(s) would the nurse use to assist the child breathe with less effort? Select all that apply. Observe for cyanosis and labored breathing every 12 hours Perform chest physiotherapy Assess pulse oximetry every 12 hours Avoid humidification of oxygen if oxygen is in use Encourage oral fluids

Encourage oral fluids Perform chest physiotherapy

wheezes

continuous high-pitched whistling sounds produced during breathing usually on expiration

An infant with a high respiratory rate is NPO and is receiving IV fluids. What assessment(s) will the nurse make to assure this infant is hydrated? Select all that apply. assess the lung sounds palpate anterior fontanel (fontanelle) measure skin turgor determine urine output review electrolyte laboratory results

palpate anterior fontanel (fontanelle) measure skin turgor determine urine output Rationale: IV fluids are necessary many times for infants and children who are experiencing highrespiratory rates. The high respiratory rates make the child very tired from the increased work ofbreathing. In an infant there are very little reserves so the infant tires very quickly, especiallywhen the work of sucking is added to the compromised respiratory state. To determine if theinfant is hydrated the nurse should assess the skin turgor, palpate for a flat anterior fontanel,observe for moist mucus membranes and measure the urine output. The urine output should be 1to 2ml/kg/hr. The electrolyte laboratory results will tell the nurse if the infant has an electrolyteimbalance, not a fluid imbalance. Assessing the lung sounds will not tell if the child is hydrated,only if the lungs are "wet" and fluid overloaded. The infant would also exhibit additional signs ofrespiratory distress if the lungs are fluid overloaded.

A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery device would the nurse most likely expect to be used?

simple mask

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

the first sign of respiratory illness in infants and children is

tachypnea