A nurse is caring for an infant weighing 7.5 kg who has had a total urine output of 93 mL over the past 12 hours.

True or False: Based on this information, the infant's urine output is within the normal range for expected urine output based on age.

Choice A rationale

Epiglottitis is a rapidly progressive, life-threatening bacterial infection causing severe swelling of the epiglottis, potentially leading to acute, complete upper airway obstruction. The most critical initial nursing action is to minimize distress and be immediately prepared for definitive airway management (intubation or tracheostomy) by the appropriate team, as the airway can close suddenly.

Choice B rationale

Racemic epinephrine is an α-adrenergic agonist used to cause vasoconstriction and reduce subglottic edema, primarily indicated for croup. Epiglottitis involves supraglottic swelling, and while it may theoretically reduce edema, the primary risk is mechanical obstruction, making preparation for airway management the priority.

Choice C rationale

While prompt intravenous antibiotic administration is essential to treat the causative bacterium, usually Haemophilus influenzae type b, this action is secondary to securing a patent airway. A patient can die from asphyxiation much faster than from bacteremia, thus airway security must be addressed first.

Choice D rationale

Attempting to obtain a throat culture in a child with suspected epiglottitis is contraindicated. Any manipulation of the posterior pharynx or epiglottis, such as using a tongue blade or swab, can trigger laryngospasm and cause immediate, complete airway obstruction, which is a catastrophic complication.

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.