A nurse is unfamiliar with a medication they are preparing to administer to a client. Prior to administering the medication, the nurse should refer to which of the following resources?

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.

Rationale for Correct Options:

1. Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

1. Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

• Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
• Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
• Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
• Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.