A 3-day-old infant is admitted for fever of 40.1°C (104.2°F) axillary. The nurse bases the care plan on the knowledge that:
The patient should be given aspirin immediately to reduce fever.
The patient likely has a hospital-acquired sepsis.
The patient's blood pressure is an early indicator of sepsis.
The patient likely acquired an infection from the mother.
The Correct Answer is D
Choice A reason: This statement is incorrect, as 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. The nurse should use other methods to reduce the fever, such as acetaminophen, tepid sponge baths, or cooling blankets.
Choice B reason: This statement is incorrect, as hospital-acquired sepsis is unlikely in a 3-day-old infant, unless the infant was exposed to invasive procedures or devices, such as catheters, ventilators, or surgery. The nurse should consider other sources of infection, such as the maternal genital tract, the umbilical cord, or the skin.
Choice C reason: This statement is incorrect, as blood pressure is not an early indicator of sepsis, but a late sign of shock. The nurse should monitor the infant for other signs of sepsis, such as temperature instability, tachycardia, tachypnea, lethargy, poor feeding, irritability, or hypoglycemia.
Choice D reason: This statement is correct, as the most common cause of sepsis in neonates is vertical transmission from the mother during pregnancy, labor, or delivery. The nurse should obtain a history of the mother's prenatal care, infections, medications, or complications, and assess the infant for any congenital anomalies or risk factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.
Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.
Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.
Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.
Correct Answer is D
Explanation
Choice A reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause is unknown, but it may be related to genetic, environmental, or hormonal factors.
Choice B reason: Slow feeding will not be sufficient to manage hypertrophic pyloric stenosis. The infant will have persistent vomiting, dehydration, and weight loss due to the obstruction of the pylorus.
Choice C reason: Dietary restrictions will not be effective for hypertrophic pyloric stenosis. The infant will not be able to tolerate any oral intake until the pylorus is surgically corrected.
Choice D reason: Surgery will be necessary to treat hypertrophic pyloric stenosis. The surgery is called pyloromyotomy, which involves cutting the thickened muscle of the pylorus to allow the stomach to empty into the duodenum.
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