Exhibits

A nurse is collecting data from an adolescent who has a new diagnosis of infectious mononucleosis. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for Correct Choices:

• Blood pressure: The adolescent's blood pressure has decreased significantly from 116/60 mm Hg to 88/50 mm Hg, indicating hypotension. This is a priority, as low blood pressure can lead to poor perfusion of vital organs and can worsen the overall condition. Immediate action, such as fluid resuscitation, is necessary.
• Temperature: The adolescent has a persistent high fever (39°C or 102.2°F), which needs to be managed to prevent complications such as febrile seizures or increased intracranial pressure, especially given the suspected meningitis. Fever management will help improve comfort and reduce metabolic demand on the body.

Rationale for Incorrect Choices:

• Nausea: While nausea is an uncomfortable symptom, it is not as urgent as hypotension. Managing blood pressure and stabilizing the adolescent's circulation takes priority before addressing nausea.
• Level of consciousness: The adolescent is lethargic but responsive to verbal stimuli. While their level of consciousness is important to monitor, it is primarily related to the underlying infection (likely meningitis). Stabilizing blood pressure and fever should be prioritized.
• Abdominal findings: The adolescent's abdominal findings (soft, flat abdomen with active bowel sounds) are not immediately concerning. The priority is managing the acute symptoms related to suspected meningitis and hypotension, rather than abdominal issues.

A. Give the infant a bottle immediately before the infant's bedtime: Feeding the infant immediately before bedtime can increase the risk of reflux as lying down soon after feeding can worsen gastroesophageal reflux. The infant should be kept upright after feeding.
B. Keep the infant at a 30-degree angle for 1 hour following each feeding: Keeping the infant upright at a 30-degree angle for about 30 to 60 minutes after feeding can help prevent the contents of the stomach from refluxing into the esophagus.
C. Limit the infant's formula feedings to every 6 hr: Infants with gastroesophageal reflux typically need more frequent feedings, not less. Limiting feedings to every 6 hours is not appropriate for a 2-month-old infant. Frequent, smaller feedings may help manage reflux.
D. Change the infant's formula to a soy-based formula: Switching to a soy-based formula is not a standard treatment for gastroesophageal reflux unless there is a specific allergy or intolerance to cow's milk protein. This should only be done if directed by the healthcare provider.