A nurse is assisting with the care of a child who is receiving palliative care. Which of the following actions should the nurse take?

A. Absence of Babinski reflex: The Babinski reflex (a fanning of the toes when the sole of the foot is stroked) is normal in infants and should be present until around 12 months of age. Its absence at 6 weeks would be atypical.
B. Absence of Moro reflex: The Moro reflex (a startle response) is typically present in newborns and may begin to disappear by 3-6 months of age. Its absence at 6 weeks would be concerning and could indicate neurological issues.
C. Closure of the posterior fontanel: The posterior fontanel typically closes by 6-8 weeks of age. This is a normal finding for a 6-week-old infant.
D. Closure of the anterior fontanel: The anterior fontanel typically closes between 12 and 18 months of age, not by 6 weeks. Therefore, closure of the anterior fontanel at 6 weeks would be unusual.

Rationale for Correct Choices:

• Acute glomerulonephritis: The child’s symptoms, such as dark brown urine (which indicates hematuria), recent history of streptococcal pharyngitis, swelling around the eyes, and slight weight loss — are highly suggestive of acute glomerulonephritis, a kidney condition that can follow a streptococcal infection. Elevated BUN and creatinine levels, along with proteinuria, also support this diagnosis.
• Encourage child to increase fluid intake: Hydration is important in managing acute glomerulonephritis, as it helps prevent further renal damage and supports kidney function. However, fluid intake should be monitored and balanced with any renal impairment and swelling.
• Restrict sodium intake: Sodium restriction is crucial in managing acute glomerulonephritis to prevent fluid retention, which can lead to worsening edema and hypertension. Given the child’s swelling and blood pressure readings, it’s important to minimize sodium intake.
• Monitor urine volume and appearance every shift: Monitoring the urine volume and appearance is key in assessing kidney function and detecting worsening of the child’s condition.
• Obtain daily weight: Daily weight monitoring helps detect fluid retention, which is common in acute glomerulonephritis due to edema. Significant weight changes may indicate worsening of kidney function or fluid balance.

Rationale for Incorrect Choices:

• Acute asthma exacerbation: While the child has a history of asthma and is showing some wheezing and a nonproductive cough, these symptoms are not the primary concern here. The child’s dark urine, swelling, and recent history of streptococcal infection are more consistent with acute glomerulonephritis than an asthma exacerbation.
• Bacterial pneumonia: Pneumonia is not indicated by the child’s symptoms. While the child has a cough and wheezing, the absence of fever, difficulty breathing, and other typical pneumonia symptoms makes this diagnosis unlikely.
• Urinary tract infection: The presence of dark urine, hematuria, and proteinuria, along with a recent streptococcal infection, points more toward acute glomerulonephritis rather than a urinary tract infection.
• Administer bronchodilators: While the child has wheezing, this is not the primary issue, as the main concern is the possible kidney involvement due to acute glomerulonephritis. Bronchodilators would be appropriate for asthma exacerbations but not for managing kidney issues.
• Administer antipyretics: There is no indication of fever at this time, and the primary concern is the renal condition. Antipyretics would only be useful if the child developed a fever.
• Administer an angiotensin-converting enzyme inhibitor : ACE inhibitors are used to treat hypertension and chronic kidney disease, but they are not typically prescribed immediately for acute glomerulonephritis without further evaluation. The child’s blood pressure is slightly elevated but not severely enough to warrant this treatment at this time.
• Monitor peak expiratory flow rate daily: This parameter is useful for monitoring asthma, but it is not relevant for assessing acute glomerulonephritis. The child’s respiratory issues are less concerning than the renal symptoms in this case.
• Obtain temperature every 4 hr: There is no indication that the child has a fever, and thus, temperature monitoring is not as critical as monitoring renal function through urine appearance, volume, and daily weight.
• Monitor oxygen saturation levels every 4 hr: While the child has some respiratory symptoms, the primary issue is related to kidney function. Oxygen saturation monitoring is more appropriate for managing respiratory conditions, not for assessing the severity of acute glomerulonephritis.