Exhibits

A nurse is collecting data from an adolescent who has a new diagnosis of infectious mononucleosis. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for Correct Choices:

• Fontanel finding: The sunken fontanel indicates signs of dehydration, which is the primary concern for this infant. Dehydration can lead to severe complications and should be addressed first through appropriate fluid resuscitation (IV fluids) to prevent further deterioration.
• Temperature: The infant has a fever of 38.4°C (101.1°F), which needs to be managed with acetaminophen as prescribed. While dehydration is the priority, the temperature should also be controlled to prevent worsening of the infant's condition and to make the child more comfortable.

Rationale for Incorrect Choices:

• Diaper area: While the excoriated diaper area is concerning, it is not the most urgent issue compared to dehydration, which can quickly worsen. Dehydration and fever management should be prioritized before addressing skin irritation.
• Stool culture results: The positive stool culture for Shigella is important for determining the infection, but addressing the infant's hydration status and fever is more urgent to stabilize the child. The results will guide further treatment but do not need immediate intervention over dehydration.
• Appetite history: While the infant's poor feeding history is significant, addressing dehydration and fever management should take precedence to stabilize the infant before evaluating feeding patterns in more detail.
• Activity tolerance finding: The infant’s fatigue is likely due to dehydration and fever. Stabilizing hydration and controlling the fever will improve the infant’s activity tolerance, making this secondary to the more urgent issues.

Rationale for Correct Choices:

• Ceftriaxone: The infant has a documented allergy to amoxicillin, and ceftriaxone is a cephalosporin antibiotic that has potential cross-reactivity with amoxicillin. Therefore, the nurse should clarify the prescription for ceftriaxone to ensure it’s safe for the infant.
• Allergy: The infant’s known allergy to amoxicillin suggests a potential allergy to ceftriaxone as well. Given the risk of anaphylaxis or other allergic reactions, the nurse must clarify the use of ceftriaxone with the healthcare provider.

Rationale for Incorrect Choices:

• Furosemide: Furosemide is a diuretic used to manage fluid retention, especially in conditions like heart failure or VSD. There are no contraindications based on the infant's current findings, such as the heart rate, medical history, or electrolyte values.
• Digoxin: Digoxin is used to help regulate heart function in infants with conditions like VSD. The infant's heart rate of 84/min is within an acceptable range for digoxin administration.
• Acetaminophen: Acetaminophen is used to manage the infant’s fever (39.2°C). Given that the infant’s temperature is elevated, acetaminophen is appropriate for fever reduction and does not require clarification.
• Ibuprofen: Ibuprofen could also be used for fever management, no immediate concerns require clarification for ibuprofen. The nurse should monitor the infant closely for any side effects, but it doesn't necessitate clarification.

• Diet: The infant's diet is not directly related to the concern about ceftriaxone administration. The infant is being fed via gastrostomy tube, and while this is a consideration for medication administration, it does not specifically affect the need to clarify ceftriaxone due to an allergy.
• Temperature: The infant’s temperature of 39.2°C indicates fever, but it is not directly related to the need to clarify the ceftriaxone prescription.
• Heart rate: The infant’s heart rate is within an acceptable range for digoxin administration (84/min), and there’s no concern regarding bradycardia or tachycardia that would require clarifying the prescription for digoxin.
• Medical history: While the infant has Down syndrome and a ventricular septal defect (VSD), which require ongoing care, the focus here is on the allergy to amoxicillin, which is directly relevant to the ceftriaxone prescription.