A nurse is caring for an infant who has thick nasal secretions, tachypnea, fever, and an oxygen saturation of 90% on room air. Which of the following actions should the nurse take?

Rationale: A. While fever may contribute to discomfort, analgesics do not address the priority problem, which is impaired oxygenation evidenced by tachypnea and an oxygen saturation of 90%. The nurse should prioritize respiratory support and oxygen monitoring rather than comfort measures. B. Infants with respiratory distress are often at risk for dehydration due to fever and increased respiratory rate. Oral intake should not be automatically limited unless there is a risk of aspiration or severe respiratory compromise. Hydration is generally encouraged, and in some cases, small frequent feeds or IV fluids may be needed. C. Peak expiratory flow measurement requires patient cooperation and is typically used in older children or adults who can follow instructions. Infants are unable to perform this test reliably, making it inappropriate. D. The infant has signs of respiratory distress (tachypnea, fever, thick secretions, and low oxygen saturation). Continuous oxygen saturation monitoring is essential. In infants, the great toe is an appropriate site for pulse oximetry, allowing accurate and continuous assessment of oxygenation status to guide further interventions such as oxygen therapy and airway suctioning.