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. "I will collect the first drop of blood by wiping it on the test strip." The first drop of blood should be wiped away with a clean cotton ball or gauze. This is because the first drop can contain interstitial fluid that may dilute the sample and lead to an inaccurate reading.
B. "I will stick the side of my finger with the lancet instead of the center." Sticking the side of the fingertip is less painful and allows for better blood flow compared to the center of the fingertip, which is often more sensitive.
C. “I will hold the lancet at a 45-degree angle when piercing my skin.” The lancet should typically be held at a 90-degree angle (straight) when piercing the skin, not at a 45-degree angle. A correct angle ensures proper blood flow and reduces discomfort.
D. “I will place my finger under cool water for a few seconds before the stick.” Using cool water before testing can cause the blood vessels to constrict. Warm water is recommended before testing, as it helps increase blood flow and makes it easier to obtain a sample.

Rationale for Correct Choices:

• Fontanel finding: The sunken fontanel indicates signs of dehydration, which is the primary concern for this infant. Dehydration can lead to severe complications and should be addressed first through appropriate fluid resuscitation (IV fluids) to prevent further deterioration.
• Temperature: The infant has a fever of 38.4°C (101.1°F), which needs to be managed with acetaminophen as prescribed. While dehydration is the priority, the temperature should also be controlled to prevent worsening of the infant's condition and to make the child more comfortable.

Rationale for Incorrect Choices:

• Diaper area: While the excoriated diaper area is concerning, it is not the most urgent issue compared to dehydration, which can quickly worsen. Dehydration and fever management should be prioritized before addressing skin irritation.
• Stool culture results: The positive stool culture for Shigella is important for determining the infection, but addressing the infant's hydration status and fever is more urgent to stabilize the child. The results will guide further treatment but do not need immediate intervention over dehydration.
• Appetite history: While the infant's poor feeding history is significant, addressing dehydration and fever management should take precedence to stabilize the infant before evaluating feeding patterns in more detail.
• Activity tolerance finding: The infant’s fatigue is likely due to dehydration and fever. Stabilizing hydration and controlling the fever will improve the infant’s activity tolerance, making this secondary to the more urgent issues.