The nurse is caring for a 1-month-old infant with respiratory ...

[wenmo]

The nurse is caring for a 1-month-old infant with respiratory syncytial virus (RSV) who is receiving 23 oxygen via a plastic hood.
 
  The child's SaO2 saturation is 88, respiratory rate is 45 breaths/min, and pulse is 140 beats/min. Based on these assessments, what action should the nurse take?
  a. Withhold feedings.
  b. Notify the health care provider.
  c. Put the infant in an infant seat.
  d. Keep the infant in the plastic hood.

Question 2

What do the initial signs of respiratory syncytial virus (RSV) infection in an infant include?
 
  a. Rhinorrhea, wheezing, and fever
  b. Tachypnea, cyanosis, and apnea
  c. Retractions, fever, and listlessness
  d. Poor breath sounds and air hunger

[kaylee05]

Answer to Question 1

ANS: B
The American Academy of Pediatrics practice parameter (2006) recommends the use of supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90. The health care provider should be notified of the saturation reading of 88. Withholding the feedings or placing the infant in an infant seat would not increase the saturation reading. The infant should be kept in the hood, but because the saturation reading is 88, the health care provider should be notified to obtain orders to increase the oxygen concentration.

Answer to Question 2

ANS: A
Symptoms such as rhinorrhea and a low-grade fever often appear first. OM and conjunctivitis may also be present. In time, a cough may develop. Wheezing is an initial sign as well. Progression of illness brings on the symptoms of tachypnea, retractions, poor breath sounds, cyanosis, air hunger, and apnea.