A 1-week-old neonate is admitted to the ED with a temperature of 39.7°C (103.5°F) axillary, HR 182, RR 76, BP 82/44, O2 saturation 96%. What are your immediate nursing priorities?
Recheck blood pressure and provide oxygen.
Administer aspirin and normal saline bolus.
Administer antibiotics and oxygen.
Obtain blood cultures, provide IV fluids and antibiotics.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as weight alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use weight in conjunction with other measures, such as height, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice B reason: This statement is incorrect, as height alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use height in conjunction with other measures, such as weight, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice C reason: This statement is incorrect, as body surface area (BSA) is not a recommended method of screening for overweight or obesity in children and adolescents, as it is not widely used or validated in this population. BSA is a measure of the total area of the skin, which can be calculated using various formulas based on weight and height. BSA is mainly used for dosing certain medications, such as chemotherapy, and for estimating the metabolic rate.
Choice D reason: This statement is correct, as body mass index (BMI) is the recommended method of screening for overweight or obesity in children and adolescents, as it is a simple and standardized measure of body fatness that can be used for comparison across different populations and age groups. BMI is calculated by dividing the weight in kilograms by the height in meters squared. The nurse should use the BMI-for-age percentile charts to interpret the BMI value and classify the child as underweight, healthy weight, overweight, or obese
Correct Answer is D
Explanation
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
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