# A 9-month-old infant is admitted to the pediatric unit with suspected RSV bronchiolitis. Which assessment finding would be the MOST concerning and require immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541905 > language: ko > subject: Infectious Diseases ## 문제 A 9-month-old infant is admitted to the pediatric unit with suspected RSV bronchiolitis. Which assessment finding would be the MOST concerning and require immediate nursing intervention? ## 보기 1. Nasal flaring with intercostal and subcostal retractions during inspiration **✔ 정답** 2. Rhinorrhea with low-grade fever of 100.2°F (37.9°C) 3. Decreased appetite and irritability when disturbed 4. Expiratory wheezing audible with stethoscope auscultation **정답: 1** ## 해설 Nasal flaring with intercostal and subcostal retractions indicates significant respiratory distress and increased work of breathing in RSV bronchiolitis, requiring immediate intervention to prevent respiratory failure. Other findings like rhinorrhea with low-grade fever, decreased appetite with irritability, and expiratory wheezing are less critical. ## 심화 해설 Clinical Reasoning and Priority Setting When assessing an infant with suspected RSV bronchiolitis, the nurse must rapidly distinguish between expected symptoms of the condition and signs of impending respiratory failure. The NCLEX-RN frequently tests the ability to prioritize care using a physiological needs framework, where airway and breathing complications take precedence. Analysis of the Correct Answer (Option 1) Nasal flaring with intercostal and subcostal retractions during inspiration is the most concerning finding. These are classic signs of severe respiratory distress in an infant. The pathophysiology involves the infant's compliant chest wall and the use of accessory muscles to generate greater negative intrathoracic pressure in an attempt to overcome airway obstruction and atelectasis caused by RSV. This clinical picture indicates that the work of breathing is significantly elevated and the child is at high risk for rapid decompensation into respiratory failure. As noted in the literature, a proportion of infants with RSV bronchiolitis develop severe disease requiring intensive care, and severe complications such as respiratory failure are a known risk [1,2]. Immediate nursing intervention, including notification of the provider, escalation of respiratory support, and preparation for potential transfer to a higher level of care, is required. Analysis of Incorrect Options Option 2: Rhinorrhea and a low-grade fever of 100.2°F (37.9°C) are typical, expected prodromal and concurrent symptoms of viral bronchiolitis. RSV is the leading cause of this infection, and most cases follow a mild-to-moderate course with these very symptoms [1,2]. While requiring supportive care, these findings do not signal an immediate life-threatening emergency. Option 3: Decreased appetite and irritability are non-specific but common findings in an infant with a respiratory infection. The increased work of breathing and general malaise from the viral illness naturally lead to poor feeding and fussiness. While these signs require monitoring for dehydration and comfort management, they are lower priority than signs of severe respiratory distress. Option 4: Expiratory wheezing is a hallmark auscultatory finding in bronchiolitis. It results from inflammation and mucus plugging in the small airways, which causes airway narrowing that is more pronounced during expiration. This is an expected finding that supports the diagnosis but does not, by itself, indicate the same level of immediate threat as the increased work of breathing demonstrated by retractions and nasal flaring. Pathophysiological Connection and Clinical Application The infant’s anatomy makes them uniquely vulnerable to severe respiratory distress. Their airways are smaller and more easily obstructed by inflammation and secretions. The horizontal angle of the ribs and a highly compliant chest wall lead to paradoxical inward movement of the chest during inspiration when intrathoracic pressure drops significantly, manifesting as retractions. This compensatory mechanism can quickly fail, leading to hypercapnia and hypoxemia. While rare, severe RSV can be complicated by life-threatening events such as spontaneous pneumothorax, which would present with a sudden worsening of these distress signs . Therefore, a nurse who observes nasal flaring and retractions must recognize this as a critical "red flag" that differentiates a stable patient from one who is actively deteriorating and requires immediate intervention. ## 임상 시나리오 Clinical Practice Guidance **Priority Assessment for RSV Bronchiolitis** In infants with suspected RSV bronchiolitis, the nurse must continuously monitor for signs of escalating respiratory distress. The presence of **nasal flaring, intercostal retractions, and subcostal retractions** indicates severe work of breathing and is a precursor to respiratory failure. These findings warrant immediate escalation of care. **Immediate Nursing Actions** - Maintain airway patency and position the infant with the head of bed elevated to optimize chest expansion. - Administer supplemental oxygen to maintain SpO2 above 90-92%, as per unit protocol. - Notify the healthcare provider or rapid response team immediately. - Prepare for potential non-invasive ventilation (e.g., high-flow nasal cannula, CPAP) or transfer to a higher level of care. - Minimize unnecessary stimulation and cluster care to reduce oxygen consumption. **Ongoing Monitoring Parameters** - Respiratory rate, depth, and pattern every 15-30 minutes or continuously if on cardiorespiratory monitor. - Oxygen saturation via continuous pulse oximetry. - Work of breathing assessment: use of accessory muscles, degree of retractions, presence of grunting. - Heart rate and perfusion status; tachycardia can be an early sign of hypoxia. - Level of consciousness and responsiveness; lethargy or irritability may indicate worsening hypoxia or hypercapnia. **Documentation Essentials** Document a focused respiratory assessment including specific retraction sites, nasal flaring, breath sounds, SpO2, and the infant's response to interventions. Record notification of the provider, orders received, and time of escalation. ## 핵심 개념 - **Nasal flaring** — A sign of increased work of breathing where the nostrils widen during inspiration, indicating severe respiratory distress in infants. - **Intercostal retractions** — Visible sinking of the skin between the ribs during inspiration, caused by high negative pressure in the chest due to airway obstruction. - **Subcostal retractions** — Inward movement of the abdomen just below the rib cage during inspiration, a sign of severe respiratory distress in young children. - **RSV bronchiolitis** — A common lower respiratory tract infection in infants caused by respiratory syncytial virus, leading to airway inflammation, mucus plugging, and possible respiratory failure. - **Respiratory failure** — A life-threatening condition where the respiratory system fails to maintain adequate gas exchange, often preceded by signs of severe distress like retractions and nasal flaring. ## 같은 주제 문제 - [A 6-month-old infant is admitted to the pediatric unit with suspected RSV bronchiolitis. 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