which of the following signs is most indicative of inadequate breathing in an infant
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Nursing Elites

ATI LPN

LPN Pediatrics

1. Which of the following signs is MOST indicative of inadequate breathing in an infant?

Correct answer: C

Rationale: Expiratory grunting is a significant sign of inadequate breathing and respiratory distress in infants. It indicates that the infant is struggling to exhale properly, which can be a sign of various respiratory issues, including lung problems or airway obstruction. Monitoring and recognizing this sign promptly can help in providing timely interventions to support the infant's breathing and prevent further complications.

2. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

3. The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching?

Correct answer: B

Rationale: The correct answer is B. Avoiding exercise entirely is not recommended for asthma management. Regular exercise can actually help strengthen the lungs and improve overall respiratory function. Teaching should focus on appropriate exercise routines that are suitable for individuals with asthma to prevent attacks. Choices A, C, and D are all appropriate and indicate good understanding of asthma management. Increasing fluid intake helps thin secretions, using the bronchodilator inhaler before the steroid inhaler follows the correct order of inhaler administration, and identifying triggers is essential for asthma control.

4. A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions?

Correct answer: A

Rationale: Mixing medication in baby food is not recommended as it can alter the taste and the child may refuse food.

5. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

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