Exhibits

A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?

Rationale:

A. Allowing the child to sit on the parent's lap can provide comfort and support during the procedure.

B. While the electrocardiogram (ECG) machine may have alarms, they are not typically related to abnormal heart rhythms during the procedure.

C. ECG leads are typically placed on the chest, not the back.

D. The duration of an ECG is relatively short, usually only a few minutes, so stating that it will take at least 30 minutes may cause unnecessary concern for the parent.

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.