A toddler is being treated for acetaminophen toxicity after an accidental overdose.
The nurse should prepare to administer which medication?

Choice A rationale

Increasing nasal discharge is a common symptom of upper respiratory tract infections and does not specifically indicate a progression to airway occlusion in croup. While it contributes to overall respiratory distress, it is not the most critical sign of a life-threatening compromise of the airway in this condition.

Choice B rationale

A harsher cough, often described as a "barking" cough, is a characteristic symptom of croup caused by inflammation of the larynx, trachea, and bronchi. While concerning, it is not the most reliable indicator of impending airway occlusion. The cough may be present throughout the illness without a complete occlusion.

Choice C rationale

An increasing respiratory rate is an early compensatory mechanism in response to airway obstruction and hypoxia. While it indicates respiratory distress, it is not the most significant sign of impending airway occlusion. It can occur with many respiratory issues and is often a precursor to more severe signs.

Choice D rationale

A toddler stating they are tired and wanting to sleep is a serious and late sign of hypoxia. This indicates that the child is becoming fatigued from the increased work of breathing, leading to decreased respiratory effort. This mental status change signals that the body's compensatory mechanisms are failing, and respiratory failure and airway occlusion are imminent.

Choice A rationale

Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. This action is not directly related to the most critical and immediate potential complication of this procedure, which is a change in the fetal heart rate. The primary concern is the potential for umbilical cord prolapse, which can lead to fetal hypoxia.

Choice B rationale

Providing a clean gown and linens is important for client comfort and hygiene, but it is not the immediate priority. The nurse must first ensure the safety of the fetus by assessing for complications that can arise from the procedure, such as umbilical cord compression or prolapse, which can lead to fetal distress and requires immediate intervention.

Choice C rationale

The immediate priority after an amniotomy is to assess the fetal heart rate. The sudden release of amniotic fluid can cause the umbilical cord to prolapse and become compressed, leading to a rapid decrease in blood flow and oxygen to the fetus. This compression results in fetal bradycardia, a critical finding requiring immediate intervention to prevent fetal hypoxia and death.

Choice D rationale

Assisting the client to wash the perineum is a hygiene measure that can be performed after the immediate safety of the fetus has been established. It is not the priority action. The nurse must first rule out any life-threatening complications to the fetus, such as cord prolapse, which is a significant risk following the rupture of membranes.