An infant is brought to the emergency department with poor skin turgor, weight loss, irritability, and tachycardia. The nurse analyzes the data to suggest:

Choice A reason: This statement is incorrect, as rechecking blood pressure and providing oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood pressure is not a reliable indicator of perfusion in neonates, and oxygen saturation is already within normal range. The nurse should focus on identifying and treating the source of infection, preventing hypovolemia and shock, and monitoring the vital signs and blood glucose levels.

Choice B reason: This statement is incorrect, as administering aspirin and normal saline bolus are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Aspirin is contraindicated in children under 18 years of age due to the risk of Reye syndrome, a rare but serious condition that affects the liver and brain. Normal saline bolus may be indicated for hypotension or shock, but only after obtaining blood cultures and starting antibiotics.

Choice C reason: This statement is incorrect, as administering antibiotics and oxygen are not the immediate nursing priorities for a neonate with fever and signs of sepsis. Antibiotics are essential for treating the infection, but they should be given after obtaining blood cultures to avoid false-negative results. Oxygen may be needed if the neonate develops hypoxia or respiratory distress, but it is not the first intervention for a neonate with normal oxygen saturation.

Choice D reason: This statement is correct, as obtaining blood cultures, providing IV fluids and antibiotics are the immediate nursing priorities for a neonate with fever and signs of sepsis. Blood cultures are necessary to identify the causative organism and guide the antibiotic therapy. IV fluids are needed to maintain hydration, perfusion, and electrolyte balance. Antibiotics are needed to eradicate the infection and prevent septic shock and organ failure.

Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.

Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.

Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.

Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.