A 1-week-old neonate is admitted to the ED with a temperature of 39.7°C (103.5°F) axillary, HR 182, RR 76, BP 82/44, O2 saturation 96%. What are your immediate nursing priorities?

Recheck blood pressure and provide oxygen.

Administer aspirin and normal saline bolus.

Administer antibiotics and oxygen.

Obtain blood cultures, provide IV fluids and antibiotics.

Answer and Explanation

The Correct Answer is D

Choice A reason: This statement is incorrect, as rechecking blood pressure and providing oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood pressure is not a reliable indicator of perfusion in neonates, and oxygen saturation is already within normal range. The nurse should focus on identifying and treating the source of infection, preventing hypovolemia and shock, and monitoring the vital signs and blood glucose levels.

Choice B reason: This statement is incorrect, as administering aspirin and normal saline bolus are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Aspirin is contraindicated in children under 18 years of age due to the risk of Reye syndrome, a rare but serious condition that affects the liver and brain. Normal saline bolus may be indicated for hypotension or shock, but only after obtaining blood cultures and starting antibiotics.

Choice C reason: This statement is incorrect, as administering antibiotics and oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Antibiotics are essential for treating the infection, but they should be given after obtaining blood cultures to avoid false-negative results. Oxygen may be needed if the neonate develops hypoxia or respiratory distress, but it is not the first intervention for a neonate with normal oxygen saturation.

Choice D reason: This statement is correct, as obtaining blood cultures, providing IV fluids and antibiotics are the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood cultures are necessary to identify the causative organism and guide the antibiotic therapy. IV fluids are needed to maintain hydration, perfusion, and electrolyte balance. Antibiotics are needed to eradicate the infection and prevent septic shock and organ failure.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.

Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.

Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.

Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.

A. Axillary temperature of 37.3° C B. Mild abdominal pain C. BP of 100/54 D. Currant jelly stools

Correct Answer is D

Explanation

Choice A reason: This is incorrect because an axillary temperature of 37.3° C is within the normal range for a 10-month-old child. It does not indicate any infection or complication after the surgery.

Choice B reason: This is incorrect because mild abdominal pain is expected after the surgery and can be managed with analgesics. It does not require immediate notification to the MD.

Choice C reason: This is incorrect because a BP of 100/54 is normal for a 10-month-old child. It does not indicate any shock or hemorrhage after the surgery.

Choice D reason: This is correct because currant jelly stools, which are stools mixed with blood and mucus, are a sign of intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. Currant jelly stools after the surgery indicate that the intussusception has recurred and requires immediate intervention. The nurse should notify the MD and prepare the child for another surgery.

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A 1-week-old neonate is admitted to the ED with a temperature of 39.7°C (103.5°F) axillary, HR 182, RR 76, BP 82/44, O2 saturation 96%. What are your immediate nursing priorities?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In providing anticipatory guidance to the mother of a two-month old breast-fed infant, which of the following should the nurse include:

Correct Answer is C

Explanation

Which assessment finding would cause the nurse to notify the MD immediately when assessing a 10-month-old child who had emergency reduction for intussusception 10 hours previously?

Correct Answer is D

Explanation

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