A 3-year-old child is brought to the emergency department by parents who report that the child was playing with small toys and suddenly began coughing violently, then became quiet but is now having difficulty breathing. What is the nurse's priority action?
The child appears anxious, is sitting upright, and has decreased breath sounds on the right side with inspiratory stridor.
1Perform back blows and chest thrusts immediately
2Prepare for immediate endotracheal intubation
3Administer high-flow oxygen via face mask
4Allow the child to remain in a position of comfort and prepare for emergency intervention✓ 정답
해설
In partial airway obstruction from foreign body aspiration, keeping the child calm in a comfortable position prevents complete obstruction while preparing for definitive removal. Back blows/chest thrusts or intubation could worsen obstruction, and oxygen alone is insufficient.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing action for a pediatric patient with a partial airway obstruction due to suspected foreign body aspiration. The core theme is managing a stable but compromised airway versus an unstable, complete obstruction. The pathophysiology involves a foreign object lodged in the bronchus (likely the right main bronchus due to its anatomical straighter path), causing ball-valve obstruction—air can enter past the object during inspiration but is trapped during expiration, leading to localized hyperinflation and decreased breath sounds.
Answer Rationale: Key Point! The child is in respiratory distress but is maintaining the airway (able to sit upright, not cyanotic). The priority is to prevent agitation that could dislodge the object and cause a complete obstruction. Allowing the child to remain in a position of comfort (often sitting up and leaning forward) minimizes crying and struggling. Simultaneously, the nurse must prepare for the definitive treatment: bronchoscopy for foreign body removal. This aligns with the nursing process of immediate assessment, creating a safe environment, and planning for urgent intervention.
Distractor Analysis:
Watch out for confusion! Option ① (Perform back blows and chest thrusts) is indicated for a conscious infant or child with a complete airway obstruction who cannot cough, cry, or breathe. This child has a partial obstruction and is moving air, so these maneuvers could convert it to a complete obstruction.
Option ② (Prepare for immediate endotracheal intubation) is incorrect. Intubation is not the first-line intervention for a foreign body obstruction. Attempting to intubate could push the object further down the airway. The definitive procedure is rigid bronchoscopy.
Option ③ (Administer high-flow oxygen) is supportive but not the priority action. Oxygen does not relieve the physical obstruction. Furthermore, applying a face mask to an anxious child could cause fighting and agitation, worsening the situation. Oxygen should be available but administered cautiously if tolerated.
Related Concepts: The management of foreign body aspiration differs dramatically based on whether the patient is an infant, child, or adult, and whether the obstruction is mild (good air exchange) or severe (poor air exchange/complete). For a conscious child with a mild partial obstruction, the guideline is to not interfere and to encourage coughing while preparing for advanced care.Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in a pediatric ED. A frantic parent runs in with a 3-year-old who is sitting rigidly, drooling slightly, with audible stridor and intercostal retractions. The parent says, "He was eating peanuts and started choking!"
Nursing Intervention Strategy:
1. Immediate Assessment (ABCs): Quickly observe without touching. Is the child coughing effectively? Can they speak or cry? Look for signs of severe distress: cyanosis, lethargy, ineffective cough. This child has stridor and retractions but is conscious and maintaining posture—indicating a partial obstruction.
2. Priority Action: Do Not Agitate: Kneel to the child's level. Speak in a calm, reassuring voice to both the child and parent. Key Point! Do not lay the child down, perform blind finger sweeps, or slap their back. Allow them to stay in the position they find easiest to breathe (usually upright).
3. Prepare for Definitive Care: While keeping the child calm, alert the respiratory therapist, physician, and OR/special procedures team STAT. Ensure a pediatric bronchoscopy tray and suction are ready. Have emergency airway equipment (including pediatric crash cart) nearby but out of the child's sight to avoid panic.
4. Monitoring & Support: Apply pulse oximetry if possible without distressing the child. Have oxygen ready via blow-by technique (holding tubing near face) if needed. Continuously monitor for deterioration into complete obstruction, which would require immediate life-saving maneuvers.
Patient Safety and Precautions: Never leave the child unattended. The transition from partial to complete obstruction can be sudden. Know the facility's protocol for activating a Code Blue or pediatric rapid response.
Nursing Procedure & Medication FlowFor Foreign Body Aspiration (Pediatric):
Activate emergency response. Begin abdominal thrusts (Heimlich) for child >1 year.
Requires immediate action to relieve complete or near-complete obstruction.
Unconscious Child
Activate Code, begin CPR, starting with chest compressions. Look in mouth only if object is visible.
CPR circulates blood; chest compressions may also create pressure to dislodge object.
A Word from Your Senior Nurse
"In the panic of a choking child, your calmness is your greatest tool. Your brain might scream 'DO SOMETHING!', but the most skilled action is often to assess, reassure, and orchestrate the right team. For a partial obstruction, you are the guardian preventing it from becoming a catastrophe. Remember: if they're coughing or making noise, the airway is open—don't shut it by intervening incorrectly. This clinical judgment is exactly what NCLEX tests."
Foreign Body Aspiration — Inhalation of an object into the respiratory tract, a common pediatric emergency. Most common in children 1-3 years old. Common objects include nuts, seeds, toy parts, and coins.
Stridor — A high-pitched, musical breathing sound caused by turbulent airflow through a partially obstructed airway at the level of the larynx or trachea. Inspiratory stridor suggests an extrathoracic obstruction.
Bronchoscopy — The definitive diagnostic and therapeutic procedure for foreign body removal. A rigid bronchoscope is typically used in children for this purpose due to better airway control and tool access.
Heimlich Maneuver (Abdominal Thrusts) — An emergency procedure to dislodge an object from the airway of a choking conscious victim over 1 year of age. It involves subdiaphragmatic abdominal thrusts to create an artificial cough.
Position of Comfort — In respiratory distress, allowing the patient to assume the posture that best facilitates breathing (e.g., tripod position, sitting upright). For a choking child, this minimizes agitation and prevents worsening of a partial obstruction.