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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Using a night-light can provide a sense of security and comfort for a child, especially if they are afraid of the dark. This can help prevent sleep problems by reducing fear and anxiety at bedtime¹.

Choice B reason: While it's true that certain foods can promote sleep, high-carbohydrate snacks before bedtime are not recommended. They can lead to energy spikes and crashes, which can disrupt sleep¹.

Choice C reason: While it's important for the sleep environment to be calming and conducive to sleep, it doesn't always have to be completely quiet and dark. Some children may find a completely dark room scary, and some background noise can actually be soothing¹.

Choice D reason: The need for naps varies greatly among children. Some 4-year-olds may still benefit from an afternoon nap. Eliminating the nap can lead to overtiredness, which can actually make it harder for the child to fall asleep at night¹.

A. Let the child hear the sounds of an ECG monitor. B. Avoid mentioning postoperative discomfort and interventions. C. Explain that an endotracheal tube will not be needed if the surgery goes well. D. Unfamiliar equipment should not be shown.

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.

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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:

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