Health Promotion and Maintenance
74. A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse?
Health Promotion and Maintenance
74. A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse?
Test-Taking Tip
Consider that grunting noises are usually heard when an individual exerts extra effort at something. Grunting during respiration is an indication that the child is working hard to breathe.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
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Answer 1 is incorrect because, although tachypnea does occur with respiratory distress, tachypnea also occurs during well states. Answer 2 is incorrect because, although scattered rhonchi are indicative of respiratory infection, the child may have rhonchi and not experience respiratory distress. Answer 3 is correct because grunting respirations indicate that the infant is attempting to increase positive airway pressure to prevent airway collapse. Answer 4 is incorrect because infants are abdominal breathers. This is an expected finding.
