Rudd Davis Advantage for Pediatric Nursing, 3rd edition. Next Generation NCLEX Instructor Questions & Answers Client is a 4-month-old male who came to the emergency room (ER) today with his mother. ... She is worried that he has a fever and is concerned about his breathing. His mother states he has been sick for 2 days. He has been running a fever (temperature max at home was 102°F [38.8°C] taken rectally), and she has noticed a lot of clear to white nasal discharge. She gave him acetaminophen about 1 hour ago. Physical Assessment: Client is sleeping and minimally arouses during assessment. Normal S1 and S2 sounds, no murmur. Normoactive bowel sounds. Expiratory wheezes and crackles heard bilaterally. Mild intercostal retractions. Pulses 2+ in all four extremities, capillary refill time less than 3 seconds. Pupils equal, round, reactive to light. Clear nasal discharge. No diaper rash noted, circumcised penis. No skin rashes noted. Vital Signs Temperature – 99.9°F (37.7°C, rectal); Respiratory Rate – 48; Pulse – 125; O2 Sat – 94% on Room Air The nurse has collected initial vital signs and completed the initial physical assessment for this client. In the previous passage, click to highlight the assessment findings or vital signs that require immediate follow-up by the nurse. 1. ANS: CLIENT CHART History and Physical Assessment Client is a 4-month-old male who came to the emergency room (ER) today with his mother. She is worried that he has a fever and is concerned about his breathing. His mother states he has been sick for 2 days. He has been running a fever (temperature max at home was 102°F [38.8°C] taken rectally), and she has noticed a lot of clear to white nasal discharge. She gave him acetaminophen about 1 hour ago.Rudd: Davis Advantage for Pediatric Nursing, 3rd edition 2 Next Generation NCLEX Questions Physical Assessment: Client is sleeping and minimally arouses during assessment. Normal S1 and S2 sounds, no murmur. Normoactive bowel sounds. Expiratory wheezes and crackles heard bilaterally. Mild intercostal retractions. Pulses 2+ in all four extremities, capillary refill time less than 3 seconds. Pupils equal, round, reactive to light. Clear nasal discharge. No diaper rash noted, circumcised penis. No skin rashes noted. Anterior fontanelle soft, flat. Vital Signs Temperature – 99.9°F (37.7°C, rectal); Respiratory Rate – 62; Pulse – 125; O2 Sat – 91% on Room Air Chapter Number and Title: Ch. 12 – Respiratory Disorders Chapter Page Reference: pg. 220, 232 Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concepts: Clinical Judgment; Infection; Oxygenation Question Type: Enhanced Hot Spot (Highlighting) Difficulty: Moderate Feedback: Recognition of respiratory distress in infants is a vital skill in the pediatric nurse. In this patient, the nurse should have recognized that change in level of consciousness (ex. minimally arouses during assessment), adventitious breath sounds (ex. expiratory wheezes and crackles heard bilaterally), mild intercostal retractions, tachypnea (ex. respiratory rate of 62), and hypoxia (ex. 91% on room air). The temperature of 99.9°F (37.7°C), while slightly elevated, is not high enough to warrant immediate followup. Elevated temperatures (>100.4°F [38°C]) can exacerbate respiratory distress and should be treated with antipyretics if the fever is causing additional distress to the client. The other assessment findings are within normal limits and appropriate for a 4-month-old. [Show More]
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