Jarvis ch. 19 - infant thorax lungs

Question 1

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.

Answer 1

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

Question 2

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

a. Crepitus palpated at the costochondral junctions
b. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume
c. Presence of bronchovesicular breath sounds in the peripheral lung fields
d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

Answer 2

ANS: C
Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults; therefore breath sounds are loud and harsh

Question 3

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.

Answer 3

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 observed with pneumonia, bronchiolitis, or atelectasis.