Health Promotion and Maintenance
32. An infant is admitted to a pediatric unit with labored breathing and moderate amounts of thick nasal secretions. What nursing intervention is most likely to improve the infant's oxygenation?
Health Promotion and Maintenance
32. An infant is admitted to a pediatric unit with labored breathing and moderate amounts of thick nasal secretions. What nursing intervention is most likely to improve the infant's oxygenation?
. Frequent suctioning of the nares with a nasal olive.
. Providing supplemental oxygen via nasal cannula.
. Strict monitoring of oxygen saturation levels.
. Placing the child in an infant seat.
Test-Taking Tip
Pay attention to both the child's symptoms and physical development in order to select the correct response. The symptom of thick nasal secretions must be addressed in terms of the infant's unique respiratory pattern of nose breathing. Only one response focuses on clearing the airway in order for the other interventions to be more successful.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is correct because infants are obligatory nose breathers. A nurse should attempt to keep nasal passages open through frequent suctioning with a nasal olive. Answer 2 is incorrect because, although supplemental oxygen may be necessary, its delivery via nasal cannula will be ineffective in an infant whose nares are blocked with thick secretions. Answer 3 is incorrect because monitoring oxygen saturations does nothing to improve oxygenation. Rather, the nurse must intervene by suctioning in order to improve saturation levels. Answer 4 is incorrect because placing the child in an infant seat does promote lung expansion through upright positioning, but the effect will be minimal if the child's nares are blocked with thick secretions.