The father of a 2-month-old infant calls the advice nurse saying his child has a fever of 38.5°C (101.3°F). The nurse should instruct the father to do which of the following?
Give the infant ibuprofen and then apply cool wet sponges to the infant.
Give the infant acetaminophen now and call back in 2 hours if the fever has not gone down.
Take the infant to the urgent care clinic now.
Put the infant in a cool bath.
The Correct Answer is C
Choice A reason: This statement is incorrect, as ibuprofen is not recommended for infants under 6 months of age due to the risk of kidney damage and bleeding. Cool wet sponges can also cause shivering and increase the body temperature. The nurse should advise the father to avoid these methods and seek medical attention.
Choice B reason: This statement is incorrect, as acetaminophen is not enough to treat a high fever in a 2-month-old infant. The nurse should also inform the father that the normal dose of acetaminophen for infants is 10 to 15 mg/kg every 4 to 6 hours, and that he should not exceed 5 doses in 24 hours. The nurse should urge the father to take the infant to the urgent care clinic as soon as possible.
Choice C reason: This statement is correct, as a fever of 38.5°C (101.3°F) or higher in an infant under 3 months of age is considered a medical emergency and requires immediate evaluation and treatment. The nurse should explain to the father that a high fever in a young infant can indicate a serious infection, such as meningitis, sepsis, or urinary tract infection, and that the infant needs to be seen by a doctor right away.
Choice D reason: This statement is incorrect, as putting the infant in a cool bath can cause hypothermia and shock. The nurse should advise the father to avoid this method and seek medical attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as rechecking blood pressure and providing oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood pressure is not a reliable indicator of perfusion in neonates, and oxygen saturation is already within normal range. The nurse should focus on identifying and treating the source of infection, preventing hypovolemia and shock, and monitoring the vital signs and blood glucose levels.
Choice B reason: This statement is incorrect, as administering aspirin and normal saline bolus are not the immediate nursing priorities for a neonate with fever and signs of sepsis. 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. Normal saline bolus may be indicated for hypotension or shock, but only after obtaining blood cultures and starting antibiotics.
Choice C reason: This statement is incorrect, as administering antibiotics and oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Antibiotics are essential for treating the infection, but they should be given after obtaining blood cultures to avoid false-negative results. Oxygen may be needed if the neonate develops hypoxia or respiratory distress, but it is not the first intervention for a neonate with normal oxygen saturation.
Choice D reason: This statement is correct, as obtaining blood cultures, providing IV fluids and antibiotics are the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood cultures are necessary to identify the causative organism and guide the antibiotic therapy. IV fluids are needed to maintain hydration, perfusion, and electrolyte balance. Antibiotics are needed to eradicate the infection and prevent septic shock and organ failure.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Letting the child hear the sounds of an ECG monitor can help reduce anxiety and fear of the unknown. It can also help the child understand what to expect during the surgery and recovery.
Choice B reason: This is not a good choice. Avoiding mentioning postoperative discomfort and interventions can create unrealistic expectations and mistrust. The nurse should provide honest and age-appropriate information about the surgery and the possible complications and pain management.
Choice C reason: This is not a good choice. Explaining that an endotracheal tube will not be needed if the surgery goes well can imply that the surgery might not go well and cause unnecessary worry. The nurse should explain that an endotracheal tube is a common device that helps the child breathe during and after the surgery and that it will be removed as soon as possible.
Choice D reason: This is not a good choice. Unfamiliar equipment should be shown and explained to the child and the family in a simple and reassuring way. This can help them become familiar with the equipment and reduce their fear and anxiety.
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