The nurse knows that auscultation of fine crackles would most ...

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The nurse knows that auscultation of fine crackles would most likely be noticed in:
 
  a. A healthy 5-year-old child.
  b. A pregnant woman.
  c. The immediate newborn period.
  d. Association with a pneumothorax.

Question 2

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and
 
  intercostal retractions. The nurse's next action should be to:
  a.
  Assure the mother that these signs are normal symptoms of a cold.
  b.
  Recognize that these are serious signs, and contact the physician.
  c.
  Ask the mother if the infant has had trouble with feedings.
  d.
  Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

[ladyjames123]

Answer to Question 1

ANS: C
Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

Answer to Question 2

ANS: B
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time.

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Thank you

[ladyjames123]

Happy to help you