Physiological Adaptation Q 8

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A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

  

     A. Prepare the child for X-ray of upper airways

     B. Examine the child’s throat

     C. Collect a sputum specimen

     D. Notify the healthcare provider of the child’s status

    

    

Correct Answer: D. Notify the healthcare provider of the child’s status

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These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.

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Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis.

Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort.

Option C: There are no indications for the collection of sputum specimens.

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