Exhibits
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
Administer ceftriaxone.
Administer pneumococcal conjugate vaccine.
Initiate serum glucose testing every 1 hr.
Initiate neutropenic precautions.
The Correct Answer is A
A. Given the cloudy appearance of the cerebrospinal fluid (CSF) and elevated white blood cell count (WBC) in the CSF, there may be an indication of meningitis.
Ceftriaxone is a broad-spectrum antibiotic commonly used to treat bacterial meningitis. Therefore, administering ceftriaxone would be an appropriate action.
B. While vaccines are important for preventing infections, administering the pneumococcal conjugate vaccine is not the immediate priority in this scenario. The patient is already exhibiting signs of a potential infection, and treatment should focus on addressing the current condition first.
C. The infant's serum glucose level is low at 64 mg/dL (normal range: 60 to 100 mg/dL).
However, the primary concern at this moment appears to be the potential bacterial meningitis indicated by the cloudy CSF, elevated WBC count, and abnormal CSF glucose level. While monitoring serum glucose is important, it is not the most critical action in this case.
D. Neutropenic precautions are typically implemented to protect patients with low neutrophil counts (neutropenia) from acquiring infections. However, there is no indication of neutropenia in the provided diagnostic results. Additionally, the cloudy CSF and elevated WBC count suggest a possible bacterial infection rather than a neutropenic condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Rolling over from back to abdomen typically occurs around 4 to 6 months of age.
While it may be slightly delayed, it is not usually concerning at 5 months.
B. Head lag at 5 months is abnormal and may indicate weakness or poor muscle tone, warranting further evaluation by the healthcare provider.
C. Not all infants are able to hold a bottle at 5 months, and this finding alone may not be concerning.
D. The grasp reflex typically diminishes by 3 to 4 months of age, so it may not be present at 5 months. While it's a developmental milestone, its absence alone may not warrant immediate concern at this age.
Correct Answer is A
Explanation
Rationale:
A. This is the priority action to confirm the correct placement of the NG tube in the stomach before administering the enteral feeding.
B. This should only be done after confirming proper tube placement.
C. Flushing the tube is necessary, but it should occur after confirming placement.
D. This should occur after confirming proper tube placement.
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