A nurse is admitting an 8-year-old child to the pediatric unit.

Exhibits

A nurse is reviewing the child's electronic medical record (EMR). Which of the following findings should the nurse identity as requiring immediate follow-up? Select the 5 findings that require immediate follow-up.

• Keep adolescent flat in bed for 24 hr post lumbar puncture: Extended flat bed rest is not recommended after lumbar puncture, as it does not prevent spinal headache and can increase discomfort. Instead, the adolescent may be kept supine only briefly for observation.

• Place the adolescent on a cooling blanket: While the adolescent has a fever of 39° C (102.2° F), a cooling blanket can cause the body to shiver, which can increase metabolic rate and raise the core temperature. A safer method is the administration of antipyretic medications like acetaminophen.

• Administer IV acyclovir: IV acyclovir is indicated for viral meningitis, particularly caused by herpes simplex virus. This adolescent’s presentation, CSF findings (low glucose, high protein, high WBC), and purpuric rash point toward bacterial meningitis, not viral etiology, making acyclovir inappropriate here.

• Place the adolescent on seizure precautions: The adolescent has developed seizure activity with tonic-clonic features, cyanosis, and pooling secretions. Seizure precautions are essential to protect from aspiration and injury, with measures such as padded side rails, suction readiness, and airway support.

• Administer IV cefotaxime: Cefotaxime is a broad-spectrum antibiotic effective against common bacterial meningitis pathogens. Given the cloudy CSF, elevated WBC, low glucose, and rapid deterioration, immediate administration of IV antibiotics is the standard, lifesaving intervention.

• Insert a peripheral IV catheter: IV access is necessary to administer fluids, antibiotics, and emergency medications. The adolescent is also showing signs of sepsis and hypotension (BP 88/50 mmHg), so fluid resuscitation and supportive therapy via IV are vital.

Rationale for Correct Choices

• Pelvic inflammatory disease: The client’s fever, pelvic pain, mucopurulent cervical discharge, elevated WBC and CRP, and positive chlamydia test point to pelvic inflammatory disease, a complication of untreated sexually transmitted infection.

• Instruct the adolescent about the use of sitz baths: Sitz baths provide localized warmth and comfort, reducing pelvic and abdominal pain while promoting circulation and relaxation in the pelvic region.

• Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen helps relieve pelvic cramping, fever, and discomfort, improving the client’s ability to tolerate care and promoting rest.

• Vaginal bleeding: PID can damage reproductive tissue, increasing risk of abnormal vaginal bleeding, so monitoring helps detect complications such as worsening infection or endometrial involvement.

• Temperature greater than 38.3° C (100.9° F): Persistent fever indicates ongoing infection or ineffective antibiotic therapy, making temperature an essential marker for evaluating treatment response.

Rationale for Incorrect Choices

• Acute appendicitis: This condition presents with right lower quadrant pain, rebound tenderness, and elevated inflammatory markers, but mucopurulent cervical discharge and positive chlamydia culture make PID more likely.

• Urinary tract infection: A UTI typically causes dysuria, frequency, and pyuria in urinalysis, but this client’s urine shows no WBCs or nitrites, making this diagnosis unlikely.

• Ectopic pregnancy: The negative hCG rules out pregnancy-related causes such as ectopic pregnancy, despite the abdominal pain.

• Maintain an NPO status: This is appropriate for appendicitis or surgical conditions, not PID, which is treated with antibiotics and comfort measures.

• Administer an enema: This is unrelated to PID management and could worsen discomfort without addressing the infection.

• Place the adolescent on bedrest in semi-Fowler’s position: This is more appropriate for appendicitis or abdominal surgery; PID management focuses on antibiotics, comfort, and symptom control instead.

• Rebound tenderness: While possible in appendicitis, this is not a priority assessment in PID, where infection signs and pelvic pain predominate.

• Presence of a Cullen sign: Cullen’s sign indicates intra-abdominal bleeding, often from ruptured ectopic pregnancy or pancreatitis, not PID.

• Irritation of the phrenic nerve: Phrenic nerve irritation, often causing shoulder tip pain, is associated with a ruptured spleen or ectopic pregnancy, and is not typical of PID.