A 3-day-old infant is admitted for fever of 40.1°C (104.2°F) axillary. The nurse bases the care plan on the knowledge that:
The patient should be given aspirin immediately to reduce fever.
The patient likely has a hospital-acquired sepsis.
The patient's blood pressure is an early indicator of sepsis.
The patient likely acquired an infection from the mother.
The Correct Answer is D
Choice A reason: This statement is incorrect, as 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. The nurse should use other methods to reduce the fever, such as acetaminophen, tepid sponge baths, or cooling blankets.
Choice B reason: This statement is incorrect, as hospital-acquired sepsis is unlikely in a 3-day-old infant, unless the infant was exposed to invasive procedures or devices, such as catheters, ventilators, or surgery. The nurse should consider other sources of infection, such as the maternal genital tract, the umbilical cord, or the skin.
Choice C reason: This statement is incorrect, as blood pressure is not an early indicator of sepsis, but a late sign of shock. The nurse should monitor the infant for other signs of sepsis, such as temperature instability, tachycardia, tachypnea, lethargy, poor feeding, irritability, or hypoglycemia.
Choice D reason: This statement is correct, as the most common cause of sepsis in neonates is vertical transmission from the mother during pregnancy, labor, or delivery. The nurse should obtain a history of the mother's prenatal care, infections, medications, or complications, and assess the infant for any congenital anomalies or risk factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Watching for signs of cyanosis and administering high dose steroids are not the first steps in managing infective endocarditis. Cyanosis is a late sign of hypoxia and steroids are not indicated for this condition.
Choice B reason: This is the correct choice. Obtaining blood cultures, administering high dose antibiotics, and assessing for cardiac decompensation are the priority interventions for a child with infective endocarditis. Blood cultures are needed to identify the causative organism and guide antibiotic therapy. High dose antibiotics are needed to eradicate the infection and prevent further damage to the heart valves. Cardiac decompensation is a serious complication of infective endocarditis that can lead to heart failure and shock.
Choice C reason: This is not a good choice. Starting high dose antibiotics, obtaining serial blood cultures, and putting the child on high flow oxygen are not the best order of management for infective endocarditis. Blood cultures should be obtained before starting antibiotics to avoid false negative results. High flow oxygen may not be necessary unless the child has signs of hypoxia or respiratory distress.
Choice D reason: This is not a good choice. Obtaining CBC, CXR and starting child on high dose aspirin are not the first steps in managing infective endocarditis. CBC and CXR are useful tests to monitor the infection and the cardiac function, but they are not as urgent as blood cultures. High dose aspirin is not recommended for infective endocarditis as it can increase the risk of bleeding.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. IV fluid bolus of 10 ml/kg is not enough to restore the circulating volume and perfusion in a child with hypovolemic shock. The recommended initial fluid bolus for pediatric hypovolemic shock is 20 ml/kg of isotonic crystalloid solution.
Choice B reason: This is the correct choice. Oxygen, IV fluid bolus of 20 ml/kg, and medications to support cardiac function are the appropriate interventions for a child with hypovolemic shock. Oxygen is given to improve oxygenation and prevent tissue hypoxia. IV fluid bolus of 20 ml/kg is given to replace the lost fluid and blood volume and improve the blood pressure and cardiac output. Medications to support cardiac function may include inotropes, vasopressors, or antiarrhythmics, depending on the child's condition and the cause of the shock.
Choice C reason: This is not a good choice. IV at 2x maintenance is not sufficient to correct the hypovolemia and shock in a child. Maintenance fluids are given to prevent dehydration and electrolyte imbalance, but they are not enough to restore the hemodynamic stability and perfusion in a child with shock. A fluid bolus is needed to rapidly increase the intravascular volume and improve the vital signs.
Choice D reason: This is not a good choice. Oxygen and medication to support cardiac function are important, but they are not enough to reverse the hypovolemic shock in a child. A fluid bolus is the first and most essential intervention to correct the hypovolemia and shock in a child. Giving medication before fluid bolus may worsen the shock and cause adverse effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.