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A nurse in an emergency department is caring for an infant.

Exhibits

The nurse on the pediatric unit is reviewing the infant's medical record immediately after receiving report from the emergency department nurse. Which of the following information requires immediate follow-up? Select all that apply.

Intake and output

Heart rate

Respiratory rate

Bowel sounds

Mucous membranes

Weight

Retractions

Lung sounds

Temperature

Oxygen saturation

Answer and Explanation

Correct Answer : A,B,C,G,H,I,J

A.   Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B.   Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C.   Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D.   Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E.   Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F.   Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G.   Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H.   Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I.   Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J.   Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Restrict the child's potassium intake. Potassium restriction is not typically required unless hyperkalemia is present.
B. Provide quiet activities for the child. Edema can cause fatigue, and quiet activities help conserve energy and reduce strain.
C. Weigh the child once a week. Daily weight monitoring is critical to track fluid retention or loss.
D. Administer acetaminophen to the child daily. Acetaminophen is not routinely required unless there is a specific indication, such as fever or pain.

A. Koplik spots B. Decreased protein in the cerebrospinal fluid C. Nuchal rigidity D. Decreased glucose in the cerebrospinal fluid

Correct Answer is C

Explanation

A. Koplik spots: These are small, white lesions on the buccal mucosa associated with measles, not meningitis.
B. Decreased protein in cerebrospinal fluid (CSF): Viral meningitis typically causes normal or slightly elevated protein levels in CSF.
C. Nuchal rigidity. Nuchal rigidity (stiff neck) is a classic sign of meningitis due to inflammation of the meninges.
D. Decreased glucose in cerebrospinal fluid: Decreased glucose in CSF is associated with bacterial meningitis, not viral.

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