A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. What should the nurse do next?

A) Ask the mother if the infant has had trouble with feedings.
B) Assure the mother that these signs are normal symptoms of a cold.
C) Recognize that these are serious signs, and contact the physician.
D) Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

The infant is an obligatory nose breather until the age of 3 months. Normally no flaring of the nostrils and no sternal or intercostal retraction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time. These signs are not normal, do not indicate heart failure, and an assessment of the infant's feeding is not a priority at this time.