The nurse has received report on the following pediatric clients. Which action should the nurse perform first?

Question

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Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first. (Option A) Intussusception can be reduced with hydrostatic enema (nonoperative approach). This is important but is not a priority over a child with bronchiolitis and respiratory distress. (Option B) Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously as it can result in lethal sepsis. The client needs cultures and empiric antibiotics. However, the client with bronchiolitis is the priority. (Option C) Increased intracranial pressure will occur with shunt malfunction. The nurse should routinely measure the head circumference, but it is not a priority over a client with respiratory distress. Educational objective: A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first.

The Nurse Has Received Report on the Following Pediatric Clients