Question

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had 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:

a. assure the mother that these are normal symptoms of a cold.
b. recognize that these are serious signs and contact the physician.
c. recognize that these are symptoms of rachitic rosary and refer the infant within the week.
d. perform a complete cardiac assessment because these are probably signs of early heart failure.

Answer 1

The nurse should recognize that nasal flaring and sternal and intercostal retractions in a 3-month-old infant are serious signs and should contact the physician immediately.

Step-by-step explanation:

The nurse should recognize that nasal flaring and sternal and intercostal retractions in a 3-month-old infant are serious signs and should contact the physician immediately. These symptoms suggest respiratory distress and may indicate a more severe condition than a common cold. Nasal flaring occurs when a person is having difficulty breathing and is a classic sign of respiratory distress. Sternal and intercostal retractions refer to the inward movement of the muscles between the ribs and at the base of the neck, which indicates increased work of breathing.

By contacting the physician, the nurse can ensure that appropriate medical attention is given to the infant, as these symptoms may require further evaluation and treatment. The nurse should document the findings and communicate them clearly to the physician.

Keywords: clinic, nasal flaring, sternal retractions, intercostal retractions, respiratory distress, common cold, physician, evaluation, treatment