# Situation: A nurse on the evening shift of a pediatric ward works with one nursing attendant. She received the endorsement at 1400 and is responsible for several children. After the endorsement, which child should the nurse see FIRST?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse on the evening shift of a pediatric ward works with one nursing attendant. She received the endorsement at 1400 and is responsible for several children.

After the endorsement, which child should the nurse see FIRST?

## 보기

1. A 2-year-old with croup, stridor at rest, suprasternal retractions, and new restlessness **✔ 정답**
2. A 3-month-old with bronchiolitis, respiratory rate 52 per minute, oxygen saturation 96%
3. A 6-year-old on day 1 after appendectomy, pain 6 out of 10, analgesic due at 1500
4. A 10-year-old with type 1 diabetes, blood glucose 250 mg/dL (13.9 mmol/L) before dinner, no ketones

**정답: 1**

## 해설

Stridor at rest with retractions and new restlessness in a child with croup signals worsening airway obstruction and possible hypoxia, which is unstable. The other children have findings that are expected for their conditions and are stable.

## 심화 해설

Priority setting after endorsement

The first child to assess is the 2-year-old with croup. The combination of stridor at rest, suprasternal retractions, and new restlessness indicates that upper airway narrowing has progressed from a mild, activity-dependent state to a critical level of obstruction that is compromising ventilation and oxygenation at rest. In croup, inflammation and edema of the subglottic region reduce the airway diameter. When a child can no longer maintain adequate airflow without using accessory muscles, and when hypoxemia or hypercarbia begins to alter mental status, the situation becomes an airway emergency.

The Pediatric Assessment Triangle (PAT) provides a structured way to understand why this child takes priority. The PAT evaluates three domains: appearance, work of breathing, and circulation to the skin. This child shows abnormalities in the first two domains. New restlessness is an early sign of hypoxemia and reflects deteriorating appearance, while stridor at rest with suprasternal retractions signals markedly increased work of breathing. In the PAT framework, a child with abnormal findings in any domain requires immediate attention; when two domains are abnormal, the child is at high risk for rapid decompensation [1].

The mechanism of deterioration in croup is progressive airway narrowing. As subglottic edema worsens, airway resistance increases exponentially because resistance is inversely related to the fourth power of the radius in a small airway. A small reduction in diameter produces a large increase in resistance. Key point! Stridor that is present only with crying or agitation may be managed with observation and humidified air, but stridor at rest means the airway is already critically narrowed even without increased demand. Suprasternal retractions indicate that the child is generating high negative intrathoracic pressure to pull air through the narrowed upper airway. Restlessness suggests the brain is sensing inadequate oxygen delivery or rising carbon dioxide levels.

Upper airway obstruction from any cause can progress rapidly in young children because their airways are anatomically smaller and more compliant. Although the case report of laryngeal leech infestation describes a different etiology, it reinforces the principle that acute upper airway obstruction in a young child is a life-threatening emergency requiring immediate recognition and intervention . The same urgency applies to croup when signs of severe obstruction appear. Post-extubation upper airway obstruction also produces stridor and respiratory distress, and research on steroid prevention in that context highlights that stridor is a marker of airway edema that can lead to reintubation if untreated . In croup, corticosteroids reduce subglottic inflammation, but their onset of action takes hours, so the immediate priority is assessment and preparation for airway support.

| Finding | Interpretation | Priority |
| --- | --- | --- |
| Stridor at rest | Airway narrowing is severe even without exertion | Immediate assessment |
| Suprasternal retractions | High negative pressure breathing; accessory muscle use | Immediate assessment |
| New restlessness | Early hypoxemia or hypercarbia; altered appearance | Immediate assessment |
| Stridor only with crying | Mild to moderate narrowing; airway patent at rest | Observe closely |

The other children have findings that are expected for their conditions and do not indicate immediate instability. The 3-month-old with bronchiolitis has a respiratory rate of 52 per minute, which is within the expected range for that age, and an oxygen saturation of 96% indicates adequate oxygenation. Bronchiolitis commonly causes tachypnea, but this child is not showing signs of severe respiratory distress such as marked retractions, nasal flaring, grunting, or hypoxemia. The 6-year-old after appendectomy has pain of 6 out of 10, which is significant but not life-threatening, and the analgesic is due at 1500; pain can be addressed after the airway emergency is managed. The 10-year-old with type 1 diabetes has a blood glucose of 250 mg/dL without ketones, which indicates hyperglycemia but not diabetic ketoacidosis; this requires insulin and monitoring but is not immediately unstable.

Watch out! In pediatric triage, a quiet child with severe airway obstruction may be mistaken for a stable child because they are not crying or fighting. However, quietness in the setting of severe obstruction can indicate exhaustion and impending respiratory failure. The restlessness in this case is a warning sign that should prompt immediate action rather than reassurance. Key point! The nurse should see the child with croup first, assess airway patency and work of breathing, administer oxygen if needed, notify the provider, and prepare for interventions such as nebulized epinephrine and systemic corticosteroids .References (research sources)

- [1]Clinical accuracy and applications of the Pediatric Assessment Triangle in emergency care: a narrative review.Research articleRath S, Alsabri M, Alhaddad J, Patel A, Chacko MM, Bucciarelli B. (2026) · DOI: 10.1186/s12245-026-01169-2

## 임상 시나리오

Pediatric Croup Airway EmergencyRecognizing Critical Upper Airway Obstruction
A child with croup who develops stridor at rest, suprasternal retractions, and new restlessness is in a state of progressive airway narrowing. The restlessness is an early sign of hypoxemia, not simply agitation.

Use the Pediatric Assessment Triangle (PAT) to prioritize. This child has abnormalities in two domains: appearance (restlessness) and work of breathing (retractions, stridor at rest). Two abnormal domains indicate a high risk of rapid decompensation.

CautionDo not agitate the child with unnecessary examination or throat swabs. Keep the child calm, allow a position of comfort, and prepare for airway support. A child with stridor at rest is an airway emergency until proven otherwise.

## 핵심 개념

- **Stridor at rest** — A high-pitched inspiratory sound heard without exertion, indicating significant upper airway narrowing.
- **Suprasternal retractions** — Visible sinking of tissues above the sternum during inspiration, a sign of increased work of breathing.
- **Pediatric Assessment Triangle (PAT)** — A rapid evaluation tool assessing appearance, work of breathing, and circulation to identify children at risk for decompensation.
- **Croup** — Viral laryngotracheobronchitis causing subglottic edema, leading to a barking cough and stridor.
- **Hypoxemia** — Low oxygen level in the blood, which can manifest as restlessness or altered mental status in children.

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