Ati n400 pediatric proctored exam e. W
The nurse identifies the following during the assessment of a 3-month-old with RSV: Heart rate of 140: Respiratory rate of 32: Oxygen saturation is 89% on room air: inspiratory and expiratory wheezing in upper lobes: temperature of 101 F: large amounts of thin secretions. What is the priority nursing action at this time?
Explanation & Rationale
Rationale: A. A quiet environment is helpful in reducing stress, but it does not address the immediate respiratory compromise. B. Oxygen therapy may be necessary, but airway clearance must be addressed first to ensure oxygen can be effectively delivered. C. Suctioning the nares and oropharynx is the priority because the infant has large amounts of secretions, which are likely obstructing the airway and contributing to low oxygen saturation. Clearing the airway will improve oxygenation and respiratory effort. D. Reducing fever is important for comfort, but does not address the urgent respiratory distress.
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