A nurse is assisting with collecting data from a 10-month-old in the emergency department.

Medical History: Guardians brought the infant to the emergency room after witnessing the infant’s arms and legs shaking.

The infant did not respond to the guardians’ voices during that time.

The episode lasted approximately 5 min and the infant was sleeping soundly afterwards.

On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation.

The infant has no prior medical or surgical history.

Born full-term at 40 weeks to a birth mother who had regular prenatal visits.

Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

The correct answer is Choice C.

Step 1: Convert the child’s weight from lbs to kg.

Since 1 lb is approximately 0.45 kg, a child who weighs 6 lbs weighs approximately 2.72 kg (6 lbs × 0.45 =2.72 kg). Step 2: Calculate the total daily dose of Ampicillin. The total daily dose is 50 mg/kg/day, so for a child who weighs 2.72 kg, the total daily dose would be approximately 136 mg (50 mg/kg/day × 2.72 kg = 136 mg/day). Step 3: Since the total daily dose is divided into q hr doses (4 doses per day), each dose would be approximately 34 mg (136 mg/day ÷ 4 doses/day = 34 mg/dose). So, the child will receive approximately 34 mg of Ampicillin with each dose.

Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.