A nurse is caring for an infant in a provider's office.

Medical History Provider Visit #1. Heart rate 144/min.

Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.

Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).

Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.

Respiratory rate 28/min.

Oxygen saturation 97% on room air.

Which of the following actions should the nurse plan to take? Select the 3 actions the nurse should plan to take.

Based on the provided medical history from the two provider visits, the infant initially presented with a fever (axillary temperature 39.7°C/103.5°F), elevated heart rate (144/min), respiratory rate (32/min), and oxygen saturation of 95% on room air. Four days later, the infant’s condition improved, with a normal temperature (37.4°C/99.3°F), slightly lower heart rate (132/min), respiratory rate (28/min), and improved oxygen saturation (97%). These findings suggest the infant likely had an acute illness, possibly an upper respiratory infection, that is resolving. The question asks for three actions the nurse should plan to take, with options related to diaper care, fluid management, and respiratory care. Since no specific diagnosis is provided, we’ll evaluate the options based on the clinical context and general pediatric nursing care for an infant recovering from a likely respiratory infection.

Evaluation of Options

A. Teach caregivers to change diapers when wet.

• Rationale: Frequent diaper changes are a standard practice to prevent diaper rash and skin irritation, which is particularly important in infants, regardless of the presence of diarrhea or other symptoms. Wet diapers can cause skin breakdown, especially in the context of illness, where skin may be more vulnerable. This is a proactive, preventive measure that aligns with general infant care.
• Relevance: This action is appropriate as part of routine caregiver education, especially in a provider’s office setting where teaching is a key nursing role. It applies broadly and is not dependent on specific symptoms beyond general infant care needs.
• Conclusion: This is a reasonable action to include.

B. Have caregivers administer 16 oz of water after each diarrhea stool.

• Rationale: The medical history does not mention diarrhea, so this action assumes a condition not supported by the data. Administering 16 oz of water per diarrhea stool is excessive for an infant, as it could lead to fluid overload or electrolyte imbalances. Infants typically require smaller, calculated fluid volumes (e.g., oral rehydration solutions) based on weight and clinical status if diarrhea is present. Without evidence of diarrhea, this action is not indicated.
• Relevance: This action is inappropriate given the lack of diarrhea in the history and the impracticality of the volume for an infant.
• Conclusion: This action should not be selected.

C. Cleanse the diaper area with soap and water.

• Rationale: Cleansing the diaper area with mild soap and water is a standard practice to maintain skin integrity and prevent infection or irritation, especially during diaper changes. This is particularly relevant for infants, who have sensitive skin, and aligns with general care recommendations, even in the absence of specific symptoms like diarrhea or rash.
• Relevance: Like option A, this is a preventive measure that supports routine infant care and caregiver education in a provider’s office setting. It complements teaching about diaper changes.
• Conclusion: This is a reasonable action to include.

D. Collect nasal drainage for culture and sensitivity.

• Rationale: The initial visit showed a fever and slightly elevated respiratory rate, suggesting a possible upper respiratory infection (URI). The improvement by the second visit (normal temperature, improved vital signs) indicates the infection is likely resolving. Collecting nasal drainage for culture and sensitivity is typically reserved for suspected bacterial infections requiring targeted antibiotic therapy (e.g., persistent or severe symptoms, suspected sinusitis). Given the infant’s improvement and lack of specific indicators (e.g., purulent nasal discharge), this action is not necessary at this stage.
• Relevance: While infection risk was a concern in the first visit, the resolution of fever and stable vital signs suggest a viral URI, which does not typically require a culture. This action is less urgent than preventive care measures.
• Conclusion: This action is not a priority.

F. Teach caregivers to apply talcum powder to creases.

• Rationale: Talcum powder is not recommended for infants due to the risk of inhalation, which can cause respiratory issues, especially in an infant with a recent respiratory illness. Modern pediatric guidelines favor keeping skin dry and using barrier creams (e.g., zinc oxide) if needed, rather than talcum powder, to prevent irritation in skin creases.
• Relevance: This action is outdated and potentially harmful, making it inappropriate for caregiver education.
• Conclusion: This action should not be selected.

G. Use a nasal aspirator after feedings.

• Rationale: The initial fever and slightly elevated respiratory rate suggest a possible URI, which could involve nasal congestion. Using a nasal aspirator can help clear mucus, improving breathing and feeding comfort, especially in infants who are obligate nose breathers. While the second visit shows improvement, mild residual congestion is possible, and teaching caregivers to use a nasal aspirator after feedings (when mucus may accumulate) is a practical, non-invasive measure to support recovery and comfort.
• Relevance: This action is relevant given the likely URI and aligns with supportive care for an infant recovering from a respiratory illness.
• Conclusion: This is a reasonable action to include.

Selected Actions

Based on the analysis, the three actions the nurse should plan to take are:

• A. Teach caregivers to change diapers when wet: Promotes skin integrity and is part of routine caregiver education.
• C. Cleanse the diaper area with soap and water: Complements diaper change teaching and prevents skin irritation.
• G. Use a nasal aspirator after feedings: Supports respiratory comfort in an infant recovering from a likely URI.

These actions focus on preventive care (A, C) and supportive management of the recent illness (G), which are appropriate for a provider’s office visit with an improving infant.

Final Answer: A, C, G