A nurse is caring for an infant who has heart failure and is receiving digoxin. Which of the following findings indicates a positive response to the medication?

Rationale for correct choices

• Preparing for a lumbar puncture: The child presents with fever, headache, nausea, irritability, lethargy, and nuchal rigidity, which are classic signs of meningitis or central nervous system infection. A lumbar puncture is the definitive diagnostic procedure to evaluate cerebrospinal fluid for infection, inflammation, or other abnormalities.

• Neurological findings: The neurological signs of lethargy, irritability, headache, and nuchal rigidity indicate possible central nervous system involvement. These findings guide the provider to order a lumbar puncture to confirm or rule out meningitis or other neurologic pathology. Early recognition and intervention are essential to prevent complications.

Rationale for incorrect choices

• Administering potassium chloride|: The child’s potassium level is 3.8 mEq/L, which is within normal limits (3.4–4.7 mEq/L). There is no indication for potassium supplementation at this time, making this intervention unnecessary.

• Administering acyclovir: Acyclovir is indicated for suspected viral infections such as herpes simplex encephalitis. While viral etiology may be considered later, the immediate priority is confirming meningitis through lumbar puncture rather than empiric antiviral therapy.

• Initiating airborne precautions: Airborne precautions are required for infections like measles, varicella, or tuberculosis. Meningitis is typically spread via droplet transmission, not airborne, so droplet precautions would be more appropriate if bacterial meningitis is suspected.

• Increasing environmental stimuli: The child exhibits irritability and lethargy; increasing stimuli could worsen agitation and interfere with assessment. The focus should be on providing a calm environment to safely evaluate neurological status.

• Lymph node findings: While lymphadenopathy may be relevant in some infections, the child’s current presentation of nuchal rigidity and neurologic symptoms takes priority for evaluation of CNS infection.

• Potassium level: Potassium is within normal limits, and there are no cardiac or metabolic indications for immediate intervention.

• Pain level: Although the child reports headache (pain 7/10), the neurological findings and risk for meningitis take precedence over pain management when anticipating a lumbar puncture.

• WBC: The WBC is elevated (14,000/mm³), which supports infection, but it alone does not dictate the need for a lumbar puncture. Neurological findings are the key indicator for this procedure.

A. Ataxia: Inhalation of gasoline, a hydrocarbon, can depress the central nervous system, leading to impaired coordination and unsteady movements. Ataxia is a common neurological manifestation in adolescents following inhalant exposure.

B. Pinpoint pupils: Pinpoint pupils are typically associated with opioid intoxication, not hydrocarbon inhalation. Gasoline inhalation does not directly affect the pupil size.

C. Hyperactive reflexes: Hydrocarbon inhalation usually depresses the central nervous system, which can lead to reduced reflexes rather than hyperactive reflexes. This finding is not expected in gasoline inhalation.

D. Hypothermia: While severe systemic toxicity may affect body temperature, mild to moderate gasoline inhalation usually does not cause hypothermia. CNS depression is more prominent than thermoregulatory effects in these cases.