Phase 3: 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. After implementing the appropriate nursing interventions, the nurse assesses the infant. For each assessment finding listed, place the finding in the appropriate category based on whether the nursing and collaborative intervention was effective (helped to meet expected outcome), ineffective (did not help to meet expected outcomes), or unrelated (not related to the expected outcome)

Effective (Helped Meet Expected Outcome) Infant is pink and responsive to stimulation: Indicates improved oxygenation and neurological status. Respirations: 69 breaths/min, saturation: 98% on 2L via HHFNC: Oxygenation has improved with supplemental oxygen, though the rate is still elevated. Nonetheless, SpO₂ is now within normal range. Infant has a wet diaper: Suggests adequate hydration and renal perfusion, which is a positive outcome of supportive care. Ineffective (Did Not Help Meet Expected Outcome): Significant nasal congestion remains: Indicates suctioning or airway clearance interventions were insufficient or need to be repeated. Subclavicular intercostal and subcostal retractions: Continued increased work of breathing means respiratory distress is still present. Unrelated (Not Related to Expected Outcome): Temperature is 100.7 °F: Mildly elevated, but not central to assessing respiratory effort or hydration in this scenario. It does not directly reflect effectiveness of current interventions for respiratory distress or hydration.