Question

While the nurse is trying to assess an infant's lungs, the infant is crying. Which conclusions should the nurse draw? Check all that apply. a. Airway is patent b. The infant may be distressed c. The infant is in need of emergency treatment d. Vocal cords are intact

Short answer

a, b, d

Step-by-step solution

Identify key observations

Notice that the infant is crying, which indicates that the infant is actively vocalizing and utilizing their respiratory system.

Analyze the crying

Since the infant is crying, this means that air is passing through the airway and that the vocal cords are likely functioning properly.

Consider distress

Crying can also be an indicator that the infant may be experiencing some form of distress but does not necessarily mean that it is an emergency situation.

Evaluate emergency need

There is no additional information suggesting that the infant requires emergency treatment from just the fact that the infant is crying.

Key concepts

Airway Patency

Airway patency is crucial for any infant's health assessment. When assessing whether an infant’s airway is patent, noticing whether they are crying can provide important clues. The fact that an infant is crying typically means that air is flowing through the airway without obstruction. This is because crying requires a clear passage for air to move in and out of the lungs. Therefore, an actively crying infant can generally be assumed to have a patent (open) airway.

Key points to remember:

• A patent airway means air can move freely from the nose and mouth to the lungs and vice versa.
• Observing crying is a simple indicator that the airway is likely open.
• Continuous crying without coughing or gasping means no evident blockage in the airway.

Respiratory System

The respiratory system of an infant includes the nose, throat, windpipe, and lungs. Proper functioning of this system is essential for the infant's survival and well-being. When an infant cries, it indicates that the respiratory system is working to some extent.

Crying involves several aspects of the respiratory system working together:

• Air must flow through the nose or mouth into the windpipe.
• The diaphragm and chest muscles must contract and relax to push air in and out of the lungs.
• Sound is produced when air moves past the vocal cords in the larynx (voice box).
• Crying necessitates coordination between breathing in (inhalation) and breathing out (exhalation).

By observing that an infant is crying, one can deduce that these components are functioning, at least to some degree.

Vocal Cords Functionality

The vocal cords are located in the larynx and are essential for producing sound. If the infant is crying, it signifies that the vocal cords are intact and functioning properly. This is because crying requires the vocal cords to vibrate as air passes through them.

Key aspects of vocal cord functionality:

• Vocal cords must be free of damage to produce sound.
• There must be enough space for air to pass and make the cords vibrate.
• Proper function of the vocal cords is crucial for normal speech and crying.
• Crying can also serve as a benchmark to evaluate if the vocal cords have suffered any injury or are inflamed.

Therefore, if an infant is crying loudly, it can be concluded that the vocal cords are likely fine.

Infant Distress Indicators

Crying is a primary indicator of distress in infants. While not all crying is a cause for alarm, it’s important to interpret the context and manner of crying to assess the infant's condition.

Possible distress signs include:

• Prolonged crying that does not stop with comforting might suggest discomfort, hunger, or pain.
• High-pitched or weak crying can be a sign of serious health issues.
• Accompanying signs such as changes in skin color (e.g., bluish lips or face), flaring nostrils, or grunting may indicate breathing problems.
• In some instances, crying can be the infant’s way of signaling less urgent needs like a diaper change or need for sleep.

Understanding these indicators helps determine whether further medical assessment or immediate intervention is needed.