6-year-old child.

Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.

Brudzinski's and Kernig's signs are positive.

Vital Signs.

Respiratory rate 28/min.

Pulse rate 120/min.

BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.

Vancomycin 300 mg IV q 6 hr following blood cultures.

Acetaminophen 240 mg PO q 6 hr PRN fever.

A nurse is planning care for a child during admission to the facility.

Which of the following actions should the nurse take first?

The correct answer is choice b. “I will hang a new bag of TPN and IV tubing every 24 hours.”

Choice A rationale:

Monitoring the client’s blood glucose level every 8 hours is important, but it is not the best indicator of understanding the TPN procedure. Blood glucose levels should be monitored regularly, but the frequency can vary based on the client’s condition and physician’s orders.

Choice B rationale:

Hanging a new bag of TPN and IV tubing every 24 hours is correct. This practice helps prevent infection and ensures the client receives the correct formulation of nutrients.

Choice C rationale:

Increasing the rate of the TPN infusion to ensure the correct amount is given is incorrect. The rate of TPN infusion should be strictly controlled and adjusted only by a physician’s order to prevent complications such as hyperglycemia or fluid overload.

Choice D rationale:

Obtaining the client’s weight every other day is important for monitoring nutritional status, but it does not directly indicate an understanding of the TPN procedure. Daily weights are often recommended to closely monitor the client’s response to TPN.

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.

Choice B rationale:

Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.

Choice C rationale:

Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.