A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

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and then

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A. "I will bathe my baby under a faucet of running water." Bathing a newborn under a running faucet increases the risk of accidental injury, sudden temperature changes, and loss of control while handling the baby. Instead, a gentle sponge bath or bathing in a small tub with controlled water temperature is recommended.
B. "I will wash my baby's face with a warm, wet washcloth without soap." This is an appropriate practice for newborn care. Using only warm water without soap helps prevent skin irritation, as a newborn’s skin is sensitive and prone to dryness. Special attention should be given to cleaning the eyes, nose, and mouth area gently.
C. "I will give my baby a bath every day." Daily bathing is not necessary for newborns and can lead to skin dryness and irritation. Instead, bathing two to three times per week is sufficient, with daily cleaning of the diaper area, face, and hands as needed.
D. "I will wash my baby's head using a moist towelette." While cleaning the baby’s head is important, a moist towelette is not the best method. The scalp should be gently washed with warm water and a mild baby shampoo to prevent buildup of oils and potential conditions like cradle cap.

Potential Condition:

Kawasaki disease: The child presents with prolonged fever, mucocutaneous changes (cracked lips, red tongue), extremity changes (edema, peeling skin), cervical lymphadenopathy, and elevated inflammatory markers (WBC, ESR, CRP, and platelets), all of which are consistent with Kawasaki disease.

Actions to Take

Administer IVIG: IVIG is the primary treatment to reduce inflammation and prevent coronary artery aneurysms.

Administer high-dose aspirin: Used in the acute phase to reduce inflammation and fever and in the subacute phase to prevent clot formation.

Parameters to Monitor

Heart rhythm: Kawasaki disease can cause myocarditis and coronary artery aneurysms, leading to arrhythmias.

Chest discomfort: A sign of coronary artery complications, including aneurysms or ischemia.

Rationale for Incorrect Diagnoses:

Bacterial endocarditis: Does not cause peeling skin or bright red tongue. Fever would be accompanied by murmurs and a history of heart defects.

Nephrotic syndrome: Characterized by severe proteinuria, edema, and hypoalbuminemia, which are absent here.

Acute post-streptococcal glomerulonephritis: Would present with recent strep infection, hematuria, hypertension, and periorbital edema, which are not mentioned.