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 D
Explanation
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Delaying dental visits until the child's heart defect is fully repaired is not a recommended practice. Dental hygiene is important for preventing oral infections that can spread to the bloodstream and cause infective endocarditis. The child should have regular dental check-ups and cleanings, as well as good oral care at home.
Choice B reason: This is the correct choice. Administration of antibiotics one hour prior to all dental procedures is a critical teaching point to emphasize for parents of a child with a complex congenital heart defect. Dental procedures can cause bleeding and bacteria to enter the bloodstream, which can infect the damaged or abnormal heart valves and cause infective endocarditis. Antibiotics can prevent or reduce the risk of this complication by killing the bacteria before they reach the heart.
Choice C reason: This is not a good choice. Administration of daily prophylactic antibiotics is not a necessary or effective measure for preventing infective endocarditis in a child with a complex congenital heart defect. Daily antibiotics can cause side effects, such as allergic reactions, diarrhea, or yeast infections. They can also lead to antibiotic resistance, which can make the bacteria harder to treat if they do cause an infection.
Choice D reason: This is not a good choice. High dose IV antibiotics for 2-8 weeks is not a preventive strategy for infective endocarditis, but a treatment option for an established infection. IV antibiotics are given to eradicate the bacteria from the bloodstream and the heart valves and prevent further damage or complications. However, IV antibiotics are not always effective and may have serious s
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