Question

the nurse observes an 18-month-old who has been admitted with a respiratory tract infection and is leaning forward with an open mouth and protruding tongue and is drooling. what should the nurse do first?

Answer 1

The nurse should first assess the child's airway, breathing, and circulation and prepare for emergency care, avoiding any procedures that could cause airway obstruction. Immediate medical assistance should be called and the child should be monitored continuously.

Step-by-step explanation:

The observed symptoms in the 18-month-old child (leaning forward with an open mouth, protruding tongue, and drooling), which could indicate a serious condition known as epiglottitis, require the nurse to act swiftly. The first action the nurse should take is to assess the child's airway, breathing, and circulation (ABCs) and prepare to provide emergency care. This is critical because epiglottitis can lead to a rapidly progressing airway obstruction. The nurse needs to avoid any procedures, like throat examination or use of a tongue depressor, that could stimulate a laryngospasm and result in complete airway obstruction. Therefore, the nurse should immediately call for medical assistance and stay with the child to provide reassurance and to monitor their airway and breathing continuously until help arrives.