A nurse is administering digoxin to an infant. The apical pulse is 88 bpm. What should the nurse do?

Choice A rationale

Decreased urine output (oliguria, typically <1 mL/kg/hour in a child) is a sign of poor renal perfusion due to reduced cardiac output and is characteristic of later, decompensated shock. In early, compensated septic shock, systemic vascular resistance (SVR) is often reduced (warm shock), and the compensatory mechanisms may still maintain adequate renal blood flow and normal urine output.

Choice B rationale

Cool extremities result from intense peripheral vasoconstriction as a compensatory mechanism to shunt blood to vital organs. This is characteristic of hypovolemic or cold septic shock (high SVR). However, in the more common early warm septic shock in children, peripheral vasodilation (low SVR) leads to flushed, warm extremities, not cool ones.

Choice C rationale

Normal blood pressure (BP) (systolic BP within the normal range, which varies by age, e.g., >90 mmHg in a school-aged child) is the hallmark of compensated shock. Compensatory mechanisms, primarily tachycardia and mild vasoconstriction, are successfully maintaining cardiac output and thus adequate mean arterial pressure, despite underlying circulatory dysfunction.

Choice D rationale

Tachycardia (elevated heart rate, normal range varies by age, e.g., >130 bpm in a toddler) is one of the earliest and most reliable signs of all forms of shock in children. It represents a critical cardiovascular compensatory mechanism to increase cardiac output (Cardiac Output = Stroke Volume×Heart Rate) in response to systemic vasodilation and early hypovolemia characteristic of sepsis.

Choice A rationale

Drooling is a hallmark sign of epiglottitis because the severe inflammation and swelling of the epiglottis make swallowing extremely painful. The child is reluctant to swallow their saliva, which pools in the mouth and causes characteristic drooling, indicating a critical impending airway obstruction.

Choice B rationale

A barking cough, often described as a "seal-like" cough, is the classic presentation of croup (laryngotracheobronchitis), which involves subglottic inflammation. Epiglottitis, in contrast, primarily involves supraglottic inflammation, leading to a blocked, or muffled, vocalization rather than the resonant, inspiratory stridor and cough of croup.

Choice C rationale

A muffled or "hot potato" voice is highly suggestive of epiglottitis. The swollen epiglottis and surrounding supraglottic structures impede the air column and vocal cord vibration, altering the quality of speech but allowing air to pass, unlike the near-complete aphonia seen in other laryngeal obstructions.

Choice D rationale

Wheezing is a high-pitched whistling sound typically heard on expiration, caused by the narrowing of the lower airways (bronchi/bronchioles), common in conditions like asthma or bronchiolitis. Epiglottitis is a supraglottic obstruction, manifesting predominantly as inspiratory stridor, not wheezing.

Choice E rationale

The tripod position (sitting upright, leaning forward with the neck hyperextended and chin thrust out) is adopted by children with epiglottitis to maximize the patency of the swollen airway and facilitate breathing. This is a sign of significant respiratory distress and impending airway failure.