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NURS 649 Ped - Respiratory Syncytial Virus HESI 2021.
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NURS 649 Ped - Respiratory Syncytial Virus HESI 2021.
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, Respiratory Syncytial Virus (RSV)Bronchiolitis
Meet the Client: Grace Hicks
Six-week-old Grace arrives in the emergency department (ED) by ambulance with
her mother Wendy. The mother states that the infant has had a 2-day history of
cold symptoms. Today, the infant became limp and cyanotic and was not
breathing. The mother revived the infant by performing mouth-to-mouth
resuscitation. An ambulance arrives, and the emergency medical technician
(EMT) stabilizes Grace before transporting the infant to the ED. This information
is reported to the nurse by the EMT upon the infant’s arrival to the ED.
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Page 1
1. Assessment
When the nurse enters the room she finds Grace crying in her mother's arms. The
nurse and Wendy calm Grace, and then the nurse auscultates the infant's lungs.
Coarse bilateral wheezes are detected, but the infant does not appear in acute
distress at this time.
2. 1.ID: 6975234130
What action should the nurse take next?
A. Perform nasal suctioning.
Since the infant is not in distress, nasal suctioning is not necessary at this
time.
B. Continue respiratory assessment. Correct
The nurse should complete the respiratory assessment, as this will provide
important baseline information for the healthcare provider
(HCP).
C. Call the emergency response team.
Since the infant is not in acute distress, calling the emergency response team
is not necessary at this time.
D. Document assessment findings.
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