A three-year-old is admitted to the pediatric medical unit with acute Kawasaki disease. What signs and symptoms are you most likely to note as you do your intake assessment?

Choice A reason: This statement is incorrect, as ibuprofen is not recommended for infants under 6 months of age due to the risk of kidney damage and bleeding. Cool wet sponges can also cause shivering and increase the body temperature. The nurse should advise the father to avoid these methods and seek medical attention.

Choice B reason: This statement is incorrect, as acetaminophen is not enough to treat a high fever in a 2-month-old infant. The nurse should also inform the father that the normal dose of acetaminophen for infants is 10 to 15 mg/kg every 4 to 6 hours, and that he should not exceed 5 doses in 24 hours. The nurse should urge the father to take the infant to the urgent care clinic as soon as possible.

Choice C reason: This statement is correct, as a fever of 38.5°C (101.3°F) or higher in an infant under 3 months of age is considered a medical emergency and requires immediate evaluation and treatment. The nurse should explain to the father that a high fever in a young infant can indicate a serious infection, such as meningitis, sepsis, or urinary tract infection, and that the infant needs to be seen by a doctor right away.

Choice D reason: This statement is incorrect, as putting the infant in a cool bath can cause hypothermia and shock. The nurse should advise the father to avoid this method and seek medical attention.

Choice A reason: Starting bolus feedings to stretch the stomach is not recommended for a child with Nissen fundoplication as it can cause increased pressure on the surgical site and lead to complications such as bleeding, perforation, or slippage of the wrap.

Choice B reason: Venting gastrostomy tube is a correct answer as it allows for the release of gas and fluids from the stomach and prevents gastric distension and discomfort. A gastrostomy tube is often placed during Nissen fundoplication to facilitate feeding and venting.

Choice C reason: Keeping child flat in bed to increase absorption of food is not advised for a child with Nissen fundoplication as it can increase the risk of aspiration and pneumonia. The child should be positioned at a 30-degree angle or higher after feeding to prevent reflux.

Choice D reason: Observing for abdominal distension, flushing and hypotension which may indicate dumping syndrome is a correct answer as it is a potential complication of Nissen fundoplication. Dumping syndrome occurs when food moves too quickly from the stomach to the small intestine, causing symptoms such as abdominal cramps, nausea, diarrhea, sweating, and dizziness.