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 C
Explanation
Choice A reason: This statement is incorrect, as Airborne Precautions are not indicated for patients with LIP, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne Precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Choice B reason: This statement is incorrect, as LIP is not rarely seen in children with AIDS, but rather one of the most common pulmonary complications of HIV infection in children. LIP affects about 30% to 40% of children with HIV, and is more prevalent in younger children than older children or adults.
Choice C reason: This statement is correct, as LIP is a common AIDS-defining condition in children with HIV. AIDS-defining conditions are illnesses that occur in people with advanced HIV infection and indicate a severe immunosuppression. LIP is a chronic inflammatory disorder of the lungs that causes lymphocytic infiltration of the interstitium and alveoli, leading to respiratory symptoms and impaired gas exchange.
Choice D reason: This statement is incorrect, as antibiotics are not the first-line treatment for LIP, unless there is a bacterial superinfection. Antibiotics do not target the underlying cause of LIP, which is the HIV infection and the associated immune dysfunction. The main treatment for LIP is antiretroviral therapy (ART), which suppresses the viral replication and improves the immune status of the patient. Corticosteroids may also be used to reduce the inflammation and improve the lung function.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Adult heart disease can cause volume overload, but so can pediatric heart disease. Volume overload is a condition where the heart has to pump more blood than normal, which can lead to heart failure and pulmonary edema. Volume overload can be caused by various factors, such as valvular defects, hypertension, or anemia.
Choice B reason: This is the correct choice. Adult heart disease is usually acquired, meaning that it develops over time due to factors such as aging, lifestyle, or infection. Pediatric heart disease is usually congenital, meaning that it is present at birth due to genetic or environmental factors that affect the development of the heart.
Choice C reason: This is not a good choice. Heart failure can occur in both adult and pediatric heart disease. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, which can lead to symptoms such as fatigue, shortness of breath, and edema. Heart failure can be caused by various factors, such as coronary artery disease, cardiomyopathy, or arrhythmias.
Choice D reason: This is not a good choice. Digoxin is a drug that can be used for both adults and children with heart disease. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, slows down the heart rate, and improves the symptoms of heart failure. Digoxin can be used for conditions such as atrial fibrillation, heart failure, or congenital heart defects. However, digoxin has a narrow therapeutic range and requires careful monitoring of the blood levels and the patient's response.
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