A nurse is caring for a toddler admitted to the hospital.

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Body system	Findings
Respiratory	Respiratory rate 264min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened Extremities cool Reports no tears
Neurologic	Lethargic

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.

A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.