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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Give 500 mg acetaminophen PO every 2 hr.

Administer a 300-mg aspirin suppository.

Place the child in an ice bath.

Lower the temperature of the room.

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is a high dose for a 2 year old child.

Choice B reason:

Aspirin is contraindicated for children with viral infections due to the risk of Reye's syndrome. It should not be administered.

Choice C reason:

Placing the child in an ice bath is an overly aggressive intervention and can lead to hypothermia. It is not recommended.

Choice D reason:

Lowering the temperature of the room is important in reducing external temperature to help cool the baby.

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Correct Answer is D

Explanation

Choice A reason:

A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.

Choice B reason:

Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.

Choice C reason:

Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.

Choice D reason:

Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.

A. Increased urinary output B. Tachycardia C. Bounding peripheral pulses D. Increased blood pressure

Correct Answer is B

Explanation

Choice A reason:

Increased urinary output is not typically associated with heart failure. In fact, heart failure often leads to decreased urine output due to decreased cardiac output.

Choice B reason:

Tachycardia (rapid heart rate) is a common manifestation of heart failure in infants. The heart compensates for decreased cardiac output by beating faster.

Choice C reason:

Bounding peripheral pulses are not typically associated with heart failure. In fact, weak peripheral pulses may be a sign of decreased cardiac output.

Choice D reason:

Increased blood pressure is not typically associated with heart failure in infants. Instead, infants with heart failure may have low or normal blood pressure.

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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

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