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 aspirin is contraindicated in children under 18 years of age due to the risk of Reye syndrome, a rare but serious condition that affects the liver and brain. The nurse should use other methods to reduce the fever, such as acetaminophen, tepid sponge baths, or cooling blankets.

Choice B reason: This statement is incorrect, as hospital-acquired sepsis is unlikely in a 3-day-old infant, unless the infant was exposed to invasive procedures or devices, such as catheters, ventilators, or surgery. The nurse should consider other sources of infection, such as the maternal genital tract, the umbilical cord, or the skin.

Choice C reason: This statement is incorrect, as blood pressure is not an early indicator of sepsis, but a late sign of shock. The nurse should monitor the infant for other signs of sepsis, such as temperature instability, tachycardia, tachypnea, lethargy, poor feeding, irritability, or hypoglycemia.

Choice D reason: This statement is correct, as the most common cause of sepsis in neonates is vertical transmission from the mother during pregnancy, labor, or delivery. The nurse should obtain a history of the mother's prenatal care, infections, medications, or complications, and assess the infant for any congenital anomalies or risk factors.

Choice A reason: This statement is correct, as breastfeeding is the best source of nutrition and hydration for infants with diarrhea, as it provides antibodies, electrolytes, and fluids. The nurse should encourage the mother to continue breastfeeding per routine, or to offer expressed breast milk if the infant is too weak or fussy to nurse.

Choice B reason: This statement is incorrect, as Imodium is not recommended for infants with diarrhea, as it can cause serious side effects, such as ileus, toxic megacolon, or central nervous system depression. The nurse should advise the parents to avoid giving any anti-diarrheal medications to the infant, unless prescribed by the doctor.

Choice C reason: This statement is incorrect, as Kaopectate is not recommended for infants with diarrhea, as it contains bismuth subsalicylate, which can cause Reye syndrome, a rare but serious condition that affects the liver and brain. The nurse should advise the parents to avoid giving any anti-diarrheal medications to the infant, unless prescribed by the doctor.

Choice D reason: This statement is incorrect, as returning to daycare 24 hours after antibiotics have been started is not appropriate for infants with diarrhea secondary to rotavirus, as antibiotics are not effective against viral infections, and the infant may still be contagious and infect other children. The nurse should instruct the parents to keep the infant at home until the diarrhea has resolved, and to practice good hand hygiene and sanitation to prevent the spread of the infection.