A nurse is assisting an infant who has respiratory syncytial virus.
For which of the following findings should the nurse intervene?
A.
Brisk capillary refill
B.
Tachypnea
C.
Rhinorrhea
D.
Coughing
The correct answer and Explanation is :
The correct answer is B. Tachypnea.
Explanation:
Respiratory syncytial virus (RSV) is a common respiratory virus that often affects infants and young children. It can cause a range of symptoms, from mild cold-like signs to severe respiratory distress. When assessing an infant with RSV, it’s crucial to monitor various indicators of respiratory distress and overall condition.
Tachypnea, or rapid breathing, is a significant finding in this context. It indicates that the infant is struggling to maintain adequate oxygen levels and is a common sign of respiratory distress. RSV can lead to inflammation and mucus production in the airways, causing the baby to breathe faster in an attempt to get more oxygen and clear the obstruction. If tachypnea is present, it may suggest that the infant’s condition is worsening, and immediate intervention may be required to prevent further respiratory compromise.
Here’s a brief overview of why the other options are less concerning compared to tachypnea:
- A. Brisk capillary refill: A brisk capillary refill (less than 2 seconds) generally indicates good peripheral perfusion and is a positive sign. It suggests that blood flow is adequate, which is important for overall health and oxygen delivery.
- C. Rhinorrhea: Rhinorrhea, or a runny nose, is a common symptom of RSV and other upper respiratory infections. While it can be uncomfortable and indicative of viral infection, it is not as critical as tachypnea and usually does not require immediate intervention unless accompanied by other severe symptoms.
- D. Coughing: Coughing is a typical symptom of RSV as the body tries to clear mucus from the airways. While persistent coughing can be distressing, it is often a natural response and less urgent compared to tachypnea.
In summary, tachypnea is the most critical finding and requires prompt attention to ensure that the infant’s respiratory needs are being adequately managed.