Level: Clinical
Difficulty: Medium
Subtopic: Respiratory illness
NCLEX: An infant has nasal flaring, grunting, retractions, and SpO2 89%. Which action is the priority?
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An infant has nasal flaring, grunting, retractions, and SpO2 89%. Which action is the priority?
Question
A. Position for airway, administer oxygen per protocol, and notify the provider.
B. Give oral fluids to prevent dehydration before assessing breathing.
C. Obtain a heel-stick glucose before any respiratory intervention.
D. Teach the parent about normal newborn sleep patterns.
B. Give oral fluids to prevent dehydration before assessing breathing.
C. Obtain a heel-stick glucose before any respiratory intervention.
D. Teach the parent about normal newborn sleep patterns.
Rationale
Correct answer: A. Position for airway, administer oxygen per protocol, and notify the provider.
Rationale: Pediatric respiratory distress with hypoxemia is an airway/breathing priority before teaching or nonurgent tasks.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Pediatric respiratory distress with hypoxemia is an airway/breathing priority before teaching or nonurgent tasks.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.