A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

A. Determine the client's Glasgow Coma Scale score: Assessing the client’s neurological status using the Glasgow Coma Scale (GCS) is the first action because it establishes a baseline for consciousness, guides priority interventions, and helps detect early deterioration. Rapid neurological assessment is critical in closed head injuries to identify life-threatening changes.

B. Prepare the client for an MRI of the brain: Imaging is important for diagnosis, but it is not the first action. The client’s neurological status must be assessed and stabilized before sending them for diagnostic procedures to ensure safety during transport and imaging.

C. Administer mannitol IV bolus to the client: Mannitol is used to reduce intracranial pressure, but administering it before assessing neurological status may not be indicated. Treatment should be guided by the assessment findings, including GCS and signs of increased intracranial pressure.

D. Insert an indwelling urinary catheter for the client: Catheterization may be necessary for monitoring output in critically ill clients, but it is not a priority over assessing neurological status. Maintaining airway, breathing, and circulation, and assessing neurologic function take precedence in head injury care.

Rationale for Correct Choices

• Swaddle the newborn in a blanket: Swaddling helps reduce heat loss through convection and evaporation, which is essential for a preterm newborn who has limited brown fat and poor thermoregulation. Maintaining warmth helps stabilize respiratory effort and metabolic demand. It is appropriate because the newborn’s temperature is below normal and continues to trend low.

• Dry the newborn: Drying reduces evaporative heat loss, which is a major risk immediately after birth, especially for late-preterm infants. Removing moisture from the skin supports temperature stabilization and reduces metabolic stress. This action is essential when temperatures remain below 36.5° C.

• Monitor the newborn’s vital signs: Frequent monitoring helps detect changes in temperature, heart rate, and respiratory drive, all of which can fluctuate rapidly in late-preterm newborns. Continuous monitoring allows the nurse to evaluate whether interventions for temperature and oxygenation are effective.

• Place the newborn under a radiant warmer: A radiant warmer provides controlled heat to support thermoregulation in preterm newborns who cannot maintain temperature independently. With temperatures at 36° C and 36.4° C, thermoregulation support is indicated to prevent cold stress. Radiant warming also helps stabilize oxygenation and metabolic rate.

• Administer free-flow oxygen: The newborn’s oxygen saturation is low at 90–91% on room air, indicating mild respiratory compromise. Providing free-flow oxygen improves oxygenation without requiring invasive airway management. This is appropriate for a newborn with increased respiratory effort but stable heart rate.

• Clear airway using bulb suction: Bulb suctioning is appropriate if secretions contribute to increased respiratory rate or difficulty maintaining saturation. Clearing the airway helps remove mucus that may impair airflow in preterm newborns. It supports spontaneous breathing and improves oxygenation.

Rationale for Incorrect Choices

• Initiate chest compressions: Chest compressions are only indicated when the newborn’s heart rate is below 60/min after at least 30 seconds of effective ventilation. This newborn’s heart rate is between 124–144/min, which is well above the threshold for resuscitation. Chest compressions are unnecessary and inappropriate for this clinical status.

• Place the newborn in prone position: Prone positioning is not recommended for routine stabilization and can compromise airway patency in a newborn requiring continuous monitoring. Supine or side-lying positioning reduces risk of airway obstruction and allows optimal chest expansion. Prone positioning increases risk for respiratory compromise in the acute period.