Walsh: Perinatal and Pediatric Respiratory Care, 3rd Edition

Chapter 06: Examination and Assessment of the Pediatric Patient

Answers to Assessment Questions and Clinical Scenarios

1.	D
Rationale: Head bobbing, nasal flaring, and grunting are common signs of respiratory distress in infants and young children and are compensatory mechanisms to decrease the work of breathing. Head bobbing occurs when the sternocleidomastoids (neck muscles that serve to flex and rotate the head), in an attempt to overcome decreased lung compliance, increased airway resistance, or both, contract during inspiration, pulling the head down and the clavicles and rib cage up (see Figure 6-1). This results in the head bobbing forward in synchrony with each inspiration.
2.	B
Rationale: In infants and young children, palpation of the chest during quiet breathing may elicit rhonchal or bronchial fremitus, which are vibrations of the chest resulting from movement of air through airways partially obstructed by mucus.
3.	E
Rationale: Stridor is a high-pitched, monophonic, audible noise that may occur during inspiration or expiration, or may be biphasic. Inspiratory stridor suggests extrathoracic airway obstruction, such as occurs in laryngomalacia, subglottic stenosis, and croup. Expiratory stridor suggests intrathoracic central airway obstruction, such as occurs in mass or vascular compression of the trachea, tracheomalacia, and bronchomalacia. Biphasic stridor typically indicates a more severe degree of laryngeal or central airway obstruction and may be associated with signs of respiratory distress. 
4.	A
Rationale: Polyphonic high-pitched wheezes typically occur in asthma and as airway obstruction worsens wheezes tend to progress from end-expiratory, expiratory, to both expiratory and inspiratory sounds. 
5.	D
Rationale: These findings are most consistent with a patient with a chronic lung disorder. Increased anteroposterior diameter suggests chronic lung hyperinflation. The finding of digital clubbing (see Figure 6-6) in a child with any respiratory condition should strongly suggest chronic hypoxia, which is common with cystic fibrosis (CF). 
6.	C
Rationale: It was noted that expiratory wheezes were best heard over the right middle and lower lobes. Unilateral wheezes or wheezes heard over a specific segment or lobe suggest foreign body airway obstruction.