Question

The nurse observes an 18-month-old who has been admitted with a respiratory tract infection who is drooling (see figure). The nurse should first:

a) position the child supine.
b) suction the airway.
c) administer oxygen.
d) call the rapid response team.

Answer 1

The nurse should immediately call the rapid response team when observing drooling in a child with a respiratory tract infection, as drooling can indicate respiratory distress and potential airway obstruction. Interventions such as administering oxygen may follow but prioritizing the rapid response is crucial. Therefore, the correct option is d.

Step-by-step explanation:

When observing an 18-month-old child admitted with a respiratory tract infection who is drooling, the nurse should prioritize maintaining the airway. Drooling can be a sign of respiratory distress and potential airway obstruction. The immediate first step should not involve positioning the child supine as this may worsen airway obstruction. Instead, the nurse should call the rapid response team to address the impending respiratory crisis. As per the guidelines, maintaining the airway and ensuring adequate oxygenation are critical during respiratory distress. While administering oxygen and suctioning the airway are important interventions, they come after alerting the rapid response team, which can provide immediate intensive care and support.

In instances like these, it's vital to follow the protocols for acute interventions which involve the activation of a multidisciplinary team capable of immediate response to prevent clinical deterioration. The knowledge of respiratory distress syndrome (RDS) underlines the importance of rapid intervention to support breathing, be it through mechanical ventilation or other means such as supplemental oxygen or CPAP if spontaneous breathing is present.