A mother brings her 3-month-old infant to the clinic for evaluation of a cold.She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment,the nurse notes that the child has nasal flaring and sternal and intercostal retractions.The nurse's next action should be to:

Question

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The infant is an obligatory nose breather until the age of 3 months.Normally,no flaring of the nostrils and no sternal or intercostal retraction occurs.Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort,as in pneumonia,acute airway obstruction,asthma,and atelectasis; therefore,immediate referral to the physician is warranted.These signs do not indicate heart failure,and an assessment of the infant's feeding is not a priority at this time.

A Mother Brings Her 3-Month-Old Infant to the Clinic for Evaluation