Shadow Health Pediatrics - Eden Wu |
Focused Exam: Respiratory Syncytial
Virus (RSV) | Complete Subjective &
1. During a focused respiratory assessment for an infant with RSV, which finding is
most consistent with increased work of breathing?
A. Respiratory rate of 30 breaths/min
B. Nasal flaring and intercostal retractions
C. Oxygen saturation of 97% on room air
D. Clear lung sounds bilaterally
Answer: B. Nasal flaring and intercostal retractions
Rationale: Nasal flaring and intercostal retractions are classic signs of increased work of
breathing in infants with RSV due to lower airway obstruction. A rate of 30 is within
normal limits for infants. Oxygen saturation of 97% and clear lung sounds do not indicate
distress.
2. Which subjective finding reported by the parent is most concerning for impending
respiratory failure in an infant with RSV?
A. Occasional dry cough
B. Decreased oral intake over 24 hours
C. Periods of apnea lasting 15 seconds
D. Mild nasal congestion
Answer: C. Periods of apnea lasting 15 seconds
Rationale: Apnea lasting 15 seconds or more is a red flag for respiratory failure in infants
with RSV, especially in those under 2 months. Decreased oral intake and mild congestion
are common but not immediately life-threatening. Occasional cough is expected.
Page 1 of 70
,3. When documenting objective data for an infant with RSV, which set of findings best
reflects a need for immediate escalation of care?
A. Temperature 37.8°C, HR 140, RR 40, SpO2 95%
B. Temperature 38.5°C, HR 180, RR 70, SpO2 88% on room air
C. Temperature 36.9°C, HR 120, RR 30, SpO2 98%
D. Temperature 37.2°C, HR 130, RR 35, SpO2 96%
Answer: B. Temperature 38.5°C, HR 180, RR 70, SpO2 88% on room air
Rationale: Tachycardia (HR 180), tachypnea (RR 70), fever, and hypoxemia (SpO2 88%)
indicate severe respiratory distress requiring immediate intervention. The other options
show age-appropriate or mildly abnormal vital signs not requiring urgent escalation.
4. Which nursing intervention is most appropriate to maintain airway clearance in an
infant with RSV who has copious secretions?
A. Administer a cough suppressant
B. Perform suctioning after instilling normal saline
C. Place the infant in a supine position
D. Encourage vigorous oral fluid intake
Answer: B. Perform suctioning after instilling normal saline
Rationale: Suctioning after saline instillation helps clear secretions and maintain a patent
airway. Cough suppressants are contraindicated as they hinder secretion clearance. Supine
positioning can worsen breathing, and oral fluids are not directly for airway clearance.
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,5. Which statement by the parent indicates a correct understanding of home care for
an infant recovering from RSV?
A. I will give my baby aspirin if the fever returns.
B. I will use a cool-mist humidifier and suction the nose before feedings.
C. I will place my baby on the stomach to sleep to help with breathing.
D. I will stop the prescribed breathing treatments once the cough improves.
Answer: B. I will use a cool-mist humidifier and suction the nose before feedings.
Rationale: Cool-mist humidification and pre-feeding suctioning ease breathing and
feeding. Aspirin is contraindicated in infants due to Reye's syndrome. Prone sleeping
increases SIDS risk. Breathing treatments should be completed as prescribed.
6. Which laboratory or diagnostic finding is most indicative of RSV bronchiolitis in an
infant?
A. Positive rapid influenza test
B. Chest X-ray showing hyperinflation and peribronchial thickening
C. Elevated white blood cell count with left shift
D. Positive blood culture for Streptococcus pneumoniae
Answer: B. Chest X-ray showing hyperinflation and peribronchial thickening
Rationale: Chest X-ray in RSV bronchiolitis typically shows hyperinflation and
peribronchial thickening due to small airway inflammation. Influenza and bacterial
infections would have different diagnostic markers. WBC elevation is nonspecific.
Page 3 of 70
, 7. When developing a care plan for an infant with RSV, which nursing diagnosis takes
highest priority?
A. Risk for infection related to compromised immune system
B. Ineffective airway clearance related to increased secretions
C. Imbalanced nutrition: less than body requirements
D. Anxiety related to hospitalization
Answer: B. Ineffective airway clearance related to increased secretions
Rationale: Ineffective airway clearance is the priority because it directly affects
oxygenation and ventilation. Nutrition, infection risk, and anxiety are important but
secondary to maintaining a patent airway.
8. Which action should the nurse take first when an infant with RSV exhibits nasal
flaring, grunting, and oxygen saturation of 89%?
A. Document the findings and reassess in 1 hour
B. Administer prescribed antipyretic
C. Apply supplemental oxygen and notify the provider
D. Offer oral fluids to keep the infant hydrated
Answer: C. Apply supplemental oxygen and notify the provider
Rationale: These signs indicate hypoxemia and respiratory distress; immediate oxygen
administration and provider notification are required. Documentation alone delays care.
Antipyretics and oral fluids do not address the airway emergency.
Page 4 of 70
Focused Exam: Respiratory Syncytial
Virus (RSV) | Complete Subjective &
1. During a focused respiratory assessment for an infant with RSV, which finding is
most consistent with increased work of breathing?
A. Respiratory rate of 30 breaths/min
B. Nasal flaring and intercostal retractions
C. Oxygen saturation of 97% on room air
D. Clear lung sounds bilaterally
Answer: B. Nasal flaring and intercostal retractions
Rationale: Nasal flaring and intercostal retractions are classic signs of increased work of
breathing in infants with RSV due to lower airway obstruction. A rate of 30 is within
normal limits for infants. Oxygen saturation of 97% and clear lung sounds do not indicate
distress.
2. Which subjective finding reported by the parent is most concerning for impending
respiratory failure in an infant with RSV?
A. Occasional dry cough
B. Decreased oral intake over 24 hours
C. Periods of apnea lasting 15 seconds
D. Mild nasal congestion
Answer: C. Periods of apnea lasting 15 seconds
Rationale: Apnea lasting 15 seconds or more is a red flag for respiratory failure in infants
with RSV, especially in those under 2 months. Decreased oral intake and mild congestion
are common but not immediately life-threatening. Occasional cough is expected.
Page 1 of 70
,3. When documenting objective data for an infant with RSV, which set of findings best
reflects a need for immediate escalation of care?
A. Temperature 37.8°C, HR 140, RR 40, SpO2 95%
B. Temperature 38.5°C, HR 180, RR 70, SpO2 88% on room air
C. Temperature 36.9°C, HR 120, RR 30, SpO2 98%
D. Temperature 37.2°C, HR 130, RR 35, SpO2 96%
Answer: B. Temperature 38.5°C, HR 180, RR 70, SpO2 88% on room air
Rationale: Tachycardia (HR 180), tachypnea (RR 70), fever, and hypoxemia (SpO2 88%)
indicate severe respiratory distress requiring immediate intervention. The other options
show age-appropriate or mildly abnormal vital signs not requiring urgent escalation.
4. Which nursing intervention is most appropriate to maintain airway clearance in an
infant with RSV who has copious secretions?
A. Administer a cough suppressant
B. Perform suctioning after instilling normal saline
C. Place the infant in a supine position
D. Encourage vigorous oral fluid intake
Answer: B. Perform suctioning after instilling normal saline
Rationale: Suctioning after saline instillation helps clear secretions and maintain a patent
airway. Cough suppressants are contraindicated as they hinder secretion clearance. Supine
positioning can worsen breathing, and oral fluids are not directly for airway clearance.
Page 2 of 70
,5. Which statement by the parent indicates a correct understanding of home care for
an infant recovering from RSV?
A. I will give my baby aspirin if the fever returns.
B. I will use a cool-mist humidifier and suction the nose before feedings.
C. I will place my baby on the stomach to sleep to help with breathing.
D. I will stop the prescribed breathing treatments once the cough improves.
Answer: B. I will use a cool-mist humidifier and suction the nose before feedings.
Rationale: Cool-mist humidification and pre-feeding suctioning ease breathing and
feeding. Aspirin is contraindicated in infants due to Reye's syndrome. Prone sleeping
increases SIDS risk. Breathing treatments should be completed as prescribed.
6. Which laboratory or diagnostic finding is most indicative of RSV bronchiolitis in an
infant?
A. Positive rapid influenza test
B. Chest X-ray showing hyperinflation and peribronchial thickening
C. Elevated white blood cell count with left shift
D. Positive blood culture for Streptococcus pneumoniae
Answer: B. Chest X-ray showing hyperinflation and peribronchial thickening
Rationale: Chest X-ray in RSV bronchiolitis typically shows hyperinflation and
peribronchial thickening due to small airway inflammation. Influenza and bacterial
infections would have different diagnostic markers. WBC elevation is nonspecific.
Page 3 of 70
, 7. When developing a care plan for an infant with RSV, which nursing diagnosis takes
highest priority?
A. Risk for infection related to compromised immune system
B. Ineffective airway clearance related to increased secretions
C. Imbalanced nutrition: less than body requirements
D. Anxiety related to hospitalization
Answer: B. Ineffective airway clearance related to increased secretions
Rationale: Ineffective airway clearance is the priority because it directly affects
oxygenation and ventilation. Nutrition, infection risk, and anxiety are important but
secondary to maintaining a patent airway.
8. Which action should the nurse take first when an infant with RSV exhibits nasal
flaring, grunting, and oxygen saturation of 89%?
A. Document the findings and reassess in 1 hour
B. Administer prescribed antipyretic
C. Apply supplemental oxygen and notify the provider
D. Offer oral fluids to keep the infant hydrated
Answer: C. Apply supplemental oxygen and notify the provider
Rationale: These signs indicate hypoxemia and respiratory distress; immediate oxygen
administration and provider notification are required. Documentation alone delays care.
Antipyretics and oral fluids do not address the airway emergency.
Page 4 of 70
