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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Letting the child hear the sounds of an ECG monitor can help reduce anxiety and fear of the unknown. It can also help the child understand what to expect during the surgery and recovery.
Choice B reason: This is not a good choice. Avoiding mentioning postoperative discomfort and interventions can create unrealistic expectations and mistrust. The nurse should provide honest and age-appropriate information about the surgery and the possible complications and pain management.
Choice C reason: This is not a good choice. Explaining that an endotracheal tube will not be needed if the surgery goes well can imply that the surgery might not go well and cause unnecessary worry. The nurse should explain that an endotracheal tube is a common device that helps the child breathe during and after the surgery and that it will be removed as soon as possible.
Choice D reason: This is not a good choice. Unfamiliar equipment should be shown and explained to the child and the family in a simple and reassuring way. This can help them become familiar with the equipment and reduce their fear and anxiety.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as atopic dermatitis (eczema) is a chronic inflammatory skin disorder that is often linked to allergic conditions, such as asthma, hay fever, or food allergies. It also has a genetic component, as it tends to run in families.
Choice B reason: This statement is incorrect, as atopic dermatitis (eczema) is not associated with upper respiratory tract infections, but rather with lower respiratory tract infections, such as bronchitis or pneumonia. Upper respiratory tract infections affect the nose, throat, and sinuses, while lower respiratory tract infections affect the lungs and airways.
Choice C reason: This statement is incorrect, as atopic dermatitis (eczema) is not easily cured, but rather a chronic and relapsing condition that requires long-term management. There is no cure for eczema, but the symptoms can be controlled with medications, moisturizers, and avoidance of triggers.
Choice D reason: This statement is incorrect, as treatment for atopic dermatitis (eczema) does not include keeping the skin dry, but rather keeping the skin moist and hydrated. Dry skin can worsen the itching and inflammation of eczema, so the nurse should advise the parents to apply emollients to the infant's skin after bathing, use mild and fragrance-free soaps and detergents, and avoid excessive heat and sweating.
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