A nurse in an emergency department is caring for a child who weighs 18 kg (39.7 lb) and ingested six 500 mg acetaminophen tablets 4 hr ago. Which of the following actions should the nurse take?

A. "Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.

B. "Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.

C. "Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.

D. "Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.

Condition most likely experiencing:

Pelvic Inflammatory Disease (PID)

Actions the nurse should take:

1. Place the adolescent on bedrest in semi-Fowler’s position
2. Administer acetaminophen 650 mg PO every 6 Hr PRN pain

Parameters to monitor:

1. Temperature greater than 38.3°C (100.9°F)
2. Rebound tenderness

Rationale:

Pelvic Inflammatory Disease (PID). The client’s history of multiple sexual partners, mucopurulent cervical discharge, pelvic pain, and fever strongly suggests PID, a bacterial infection often caused by sexually transmitted infections (STIs) such as chlamydia or gonorrhea.

Urinary tract infection. UTIs typically present with dysuria, urgency, frequency, and suprapubic pain, which are not noted here.

Ectopic pregnancy. The client’s last menstrual period was 7 days ago, making pregnancy unlikely. PID symptoms differ from ectopic pregnancy, which presents with unilateral lower abdominal pain and possibly vaginal bleeding.

Acute appendicitis. Appendicitis typically causes right lower quadrant pain, nausea, vomiting, and rebound tenderness, which are not the primary symptoms here.

Place the adolescent on bedrest in semi-Fowler’s position – This promotes drainage of infected fluids and reduces the risk of abscess formation.

Administer acetaminophen 650 mg PO every 6 Hr PRN pain – This helps manage the pain associated with PID.

Temperature greater than 38.3°C (100.9°F) – A rising temperature may indicate worsening infection or sepsis.

Rebound tenderness – Can indicate peritoneal irritation, which may suggest complications such as peritonitis or an abscess.

Instruct the adolescent about the use of sitz baths. Sitz baths are used for perineal discomfort but are not a standard intervention for PID.

Administer an enema. An enema is unnecessary and could worsen the infection if peritonitis is present.

Vaginal bleeding. Vaginal bleeding is not a common symptom of PID.

Irritation of the phrenic nerve. Phrenic nerve irritation is associated with diaphragmatic irritation, such as in gallbladder disease or ruptured ectopic pregnancy.

Presence of a Cullen sign. Cullen’s sign (bluish discoloration around the umbilicus) is a sign of intra-abdominal hemorrhage, often seen in ruptured ectopic pregnancy or pancreatitis, not PID.