The father of a 2-month-old infant calls the advice nurse saying his child has a fever of 38.5°C (101.3°F). The nurse should instruct the father to do which of the following?
Give the infant ibuprofen and then apply cool wet sponges to the infant.
Give the infant acetaminophen now and call back in 2 hours if the fever has not gone down.
Take the infant to the urgent care clinic now.
Put the infant in a cool bath.
The Correct Answer is C
Choice A reason: This statement is incorrect, as ibuprofen is not recommended for infants under 6 months of age due to the risk of kidney damage and bleeding. Cool wet sponges can also cause shivering and increase the body temperature. The nurse should advise the father to avoid these methods and seek medical attention.
Choice B reason: This statement is incorrect, as acetaminophen is not enough to treat a high fever in a 2-month-old infant. The nurse should also inform the father that the normal dose of acetaminophen for infants is 10 to 15 mg/kg every 4 to 6 hours, and that he should not exceed 5 doses in 24 hours. The nurse should urge the father to take the infant to the urgent care clinic as soon as possible.
Choice C reason: This statement is correct, as a fever of 38.5°C (101.3°F) or higher in an infant under 3 months of age is considered a medical emergency and requires immediate evaluation and treatment. The nurse should explain to the father that a high fever in a young infant can indicate a serious infection, such as meningitis, sepsis, or urinary tract infection, and that the infant needs to be seen by a doctor right away.
Choice D reason: This statement is incorrect, as putting the infant in a cool bath can cause hypothermia and shock. The nurse should advise the father to avoid this method and seek medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect, as pedialyte is not the best thing for the child who is refusing to drink it, as it can cause dehydration and electrolyte imbalance. The nurse should not force the child to drink pedialyte, but rather offer alternatives that are more appealing and acceptable to the child.
Choice B reason: This statement is correct, as pedialyte is the best thing for the child who has diarrhea and vomiting, as it can prevent dehydration and electrolyte imbalance. The nurse should encourage the parent to give pedialyte to the child, but also respect the child's preferences and autonomy. The nurse should suggest different ways to make pedialyte more palatable and fun for the child, such as using a spoon, a medicine cup, a syringe, or a popsicle.
Choice C reason: This statement is incorrect, as clear diet soda is not a good option for the child who has diarrhea and vomiting, as it can worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to avoid giving soda to the child, as it contains caffeine, sugar, and carbonation, which can irritate the stomach and intestines, and increase the fluid loss.
Choice D reason: This statement is incorrect, as it does matter what the child drinks, as some fluids can help or harm the child's hydration and electrolyte status. The nurse should educate the parent about the best and worst fluids for the child who has diarrhea and vomiting, and recommend pedialyte as the first choice. The nurse should also instruct the parent to give small and frequent amounts of fluids to the child, and to monitor the urine output, weight, and signs of dehydration.
Correct Answer is D
Explanation
Choice A reason: An axillary temperature of 37.3° C is within the normal range for a 10 month old child and does not indicate a complication of intussusception or its treatment.
Choice B reason: Mild abdominal pain is expected after an emergency reduction for intussusception and can be managed with analgesics and comfort measures.
Choice C reason: A BP of 100/54 is normal for a 10 month old child and does not reflect hypovolemia or shock, which are possible complications of intussusception.
Choice D reason: Currant jelly stools are a sign of intestinal bleeding and ischemia, which are serious complications of intussusception that require immediate medical attention. Currant jelly stools are red, mucus-like, and mixed with blood. They indicate that the intussusception has not been resolved or has recurred.
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