Phase 1 A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside. Choose the most likely options for the information missing from the statements below by choosing from the corresponding list. Based on the infant’s assessment data, the nurse determines that the infant’s abnormal vital sign findings are most likely due to _____ and _____. The priority action is oxygenation and nasal clearing. Nursing actions for nasal airway clearing include: _____, _____, and _____.

The elevated heart rate (178 bpm), tachypnea (RR 65), oxygen saturation of 92% on room air, retractions, head bobbing, and restlessness all point to respiratory distress. The delayed capillary refill (>4 seconds) and inability to stay latched to the breast suggest dehydration, likely from poor oral intake and increased insensible fluid losses through tachypnea. These interventions help improve oxygenation by clearing mucus obstructing the nasal passages (especially important for obligate nose-breathers like young infants) and providing supplemental oxygen. Rationale for Incorrect Options: Deep suctioning: Generally reserved for severe cases and requires provider order; may be too invasive initially. Hunger: While hunger may cause fussiness, it is not a primary concern in this clinical picture. Pain: Not supported by the current assessment findings; signs point more clearly to respiratory issues.