RSV
Phase 1
A 10 week old is brought to the emergency room with three days of rhinorrhea, congestion and cough.
Mother feels the infant is in needs help breathing and states he has been unable to breast feed all day.
Infant is exclusively breastfed. Older sibling is at home with respiratory illness as well.
Vital Signs:
Temperature: 99.2 F
Heart Rate: 178 beats/min
Respirations: 65 breaths/min
Oxygen Saturation: 92% (on room air)
No Known Allergies
Born at 39 weeks
Up to date with vaccines
Physical Assessment:
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Mild intercostal retractions
Restless and head bobbing
Intermittent wheezing in both lungs
Congested cough
Unable to stay latched to breast
Capillary Refill: 4 seconds
Extremity Pulses: +2
Mother at bedside
NGN Item: Enhanced Hot Spot
Question 1
Highlight or place a check mark next to the assessment findings that require follow up by the
nurse.
NGN Item: Cloze
Question 2
Choose the most likely options for the information missing from the statements
below by selecting from the lists of options provided.
Based on the infant’s assessment data, the nurse determines that the infant’s abnormal
vital sign findings are most likely due to __________1__________ and ________1_________. The
priority action is oxygenation and nasal clearing. Nursing actions for nasal airway clearing
include: __________2__________, ________2_________ and ________2________.
Options for 1
Respiratory Distress
Pain
Hunger
Options for 2
Nasal Suctioning
Oxygen via Nasal Cannula
Normal Saline (for suctioning)
Dehydration
Deep Suctioning
Phase 2
The infant is treated in the emergency department with nasal suctioning and blow by oxygen at 100%.
Albuterol is given for wheezing with no effect. A chest x-ray is ordered. The infant improves slightly with
a decrease in respiratory rate, but still has significant nasal congestion. Rapid laboratory testing for
respiratory viral panel is pending with a probable diagnosis of bronchiolitis. The infant is admitted to the
acute care unit for ongoing care.
NGN Item: Extended Multiple Response
Question 3
Which of the following complications will the nurse anticipate when caring for this infant? Select all that
apply.
1.
2.
3.
4.
5.
6.
7.
8.
Respiratory Failure
Dehydration
Fatigue
Vomiting
Infection
Pulmonary edema
Hypoxemia
Apnea
NGN Item: Extended Drag and Drop
Question 4
Use an X to indicate whether the nursing actions below are Indicated (appropriate or necessary),
Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the
infant’s care during hospitalization.
Nursing Action
Monitor the infant’s
respiratory rate every 2
hours.
Conduct
Nasopharyngeal
suctioning every 4
hours
Review chest x-ray and
lab results
Administer
supplemental infant
formula in leu of
breastmilk
Utilize normal saline
drops during nasal
suctioning
Provide anticipatory
guidance education
regarding nasal
suctioning at home
Provide oxygen for O2
saturation less than
90% via HHFNC
(heated, high-flow
nasal cannula)
Indicated
Contraindicated
Non-Essential
Phase 3
Several hours after being admitted to the acute care, the nurse finds the infant to have increased
retractions, now including subclavicular, intercostal and subcostal retractions along with tracheal
tugging and nasal flaring. The infant continues to have wheezing with a respiratory rate of 80
breaths/min, oxygen saturation of 86% on blow by oxygen and a temperature of 102.1 F. The infant
appears dusky, fatigued, and slow to react.
Question 5
NGN Item: Extended Multiple Response
Which nursing actions are indicated for the infant’s care at this time? Select all that apply.
A.
B.
C.
D.
E.
F.
Administer IV antibiotic therapy as prescribed
Assess the infant’s airway and perform nasal suctioning as needed.
Administer oxygen via a HHFNC (heated, high-flow nasal cannula)
Administer antipyretics as prescribed
Encourage oral fluids to prevent dehydration
Administer Albuterol as prescribed
NGN Item: Matrix
Question 6
After implementing the appropriate nursing interventions, the nurse assesses the infant. For each
assessment finding, use an X to indicate whether nursing and collaborative interventions
were Effective (helped to meet expected outcomes), Ineffective (did not help to meet
expected outcomes), or Unrelated (not related to the expected outcomes).
Assessment Finding
Subclavicular, intercostal and
subcostal retractions present
Temperature is 100.7 F
Infant is pink and responsive to
stimulation
Respirations: 69 breaths/min
Oxygen Saturation: 98% on 2L
HHFNC
Significant nasal congestion
remains
Infant has a wet diaper
Effective
Ineffective
Unrelated