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An oxygen saturation of 88.

Bounding peripheral pulses are a classic finding in Patent Ductus Arteriosus (PDA) due to the wide pulse pressure, which results from the run-off of blood from the aorta back into the pulmonary artery during diastole. This finding supports the diagnosis but is not typically the most concerning indicator of impending decompensation.

The machinery-like murmur is the pathognomonic sign of a Patent Ductus Arteriosus, caused by continuous blood flow from the high-pressure aorta to the low-pressure pulmonary artery. This is an expected diagnostic finding for PDA, confirming the presence of the defect, but it is not an indicator of acute distress.

Furosemide is a loop diuretic that promotes the excretion of sodium and water, reducing fluid overload and pulmonary congestion associated with congestive heart failure. A decreased urine output of 0.5 mL/kg/hr is a sign of worsening status, as the target output for adequate diuresis is generally 1-3 mL/kg/hr for children.

Furosemide therapy is intended to reduce fluid volume, which should result in weight loss. An increase in weight of 1.5 kg indicates fluid retention and ineffective or inadequate diuretic therapy, signaling a deterioration or lack of improvement in the child's congestive heart failure.

An increase in heart rate to 160 bpm (tachycardia) in a school-aged child (normal resting heart rate ≈ 70-110 bpm) is a compensatory mechanism for decreased stroke volume, often seen in worsening heart failure or dehydration. This finding indicates deterioration or a negative effect of the diuretic, such as volume depletion.

While benzodiazepines (like rectal or intranasal diazepam or midazolam) are used to stop seizures, this is done via a non-oral route as the child is typically unconscious and unable to safely swallow during a seizure, posing a severe aspiration risk. Oral administration is contraindicated during the acute seizure event itself.

Inserting a tongue blade or any object into the mouth during a seizure is strictly contraindicated. The child's jaw may clamp down forcefully, causing injury to the child's teeth, gums, or jaw, or causing the object to break and obstruct the airway, leading to far more harm than benefit.

Restraining the child during a seizure is inappropriate and dangerous. The forceful muscle contractions can cause injury (fractures or dislocations) if movement is restricted against the convulsive forces. The nurse's role is to clear the area and protect the head and limbs from striking hard objects.

Administering half the dose is inappropriate and lacks a scientific basis unless ordered by the provider, as it would likely be sub-therapeutic and fail to achieve the desired effect of improving myocardial contractility and reducing heart rate. Digoxin administration should be all or none based on parameters.

The acceptable apical pulse rate for administering digoxin to an infant is typically above 90-110 beats per minute (bpm). An apical pulse of 88 𝐛𝐩𝐦 falls below this generally accepted cutoff, indicating potential drug toxicity or the therapeutic effect lowering the rate too much, necessitating withholding the dose.

Administering double the dose is a dangerous, unscientific action that would significantly increase the risk of 𝐝𝐢𝐠𝐨𝐱𝐢𝐧 toxicity, which can cause severe cardiac arrhythmias, gastrointestinal symptoms, and potential cardiac arrest, particularly in infants who are highly susceptible to small dose changes.

Hypotonic saline is not the fluid of choice for septic shock because it lowers serum osmolality and can shift fluid into the cells, worsening intravascular volume depletion and hypotension. A 20 mL/kg bolus is the correct volume, but the fluid type and 10 minutes duration are inappropriate for initial resuscitation.

The volume of 5 𝐦𝐋/𝐤𝐠 is insufficient for the initial resuscitation of a child in septic shock, where the goal is rapid, aggressive replacement of intravascular volume lost due to capillary leak and vasodilation. A 20 𝐦𝐋/𝐤𝐠 bolus is the standard. Ringer's lactate is an acceptable crystalloid, but the volume is wrong.

𝐃5𝐖 (5.

A mild headache is a very common and expected symptom following a concussion, resulting from the temporary biomechanical injury to brain tissue or surrounding structures. This symptom alone typically does not indicate an immediate neurological deterioration or an expanding intracranial lesion, provided it doesn't rapidly worsen in severity or become refractory to simple analgesics. Management generally involves rest and observation.

Alertness indicates an intact reticular activating system (RAS), which is crucial for consciousness. Maintaining an alert mental status is a positive sign that suggests the primary brain centers are functioning adequately and the ICP is not critically elevated. A decreased level of consciousness would be a much more concerning indicator of neurological decline.

A normal gait reflects proper coordination of motor, sensory, and cerebellar functions. Gross neurological integrity suggests that the cerebral and cerebellar pathways, which govern balance and movement, are not significantly compromised. An abnormal gait, like ataxia, would be a sign of focal neurological deficit or severe intracranial pressure.

A high-pitched cry in an infant can be indicative of increased intracranial pressure (ICP) due to stretching of the meninges or irritation of the central nervous system. However, it is a non-specific sign that may also relate to pain or general distress. Normal infant crying is variable, but this specific quality suggests a potentially serious neurological issue.

Poor feeding is a non-specific sign of general illness in an infant, reflecting overall malaise or potentially a depressed level of consciousness secondary to increased ICP. Reduced appetite or difficulty sucking/swallowing suggests decreased neurological function or systemic distress but is often less immediately concerning than vital sign changes.

Separated cranial sutures (diastasis) and a bulging fontanelle are classic, late-stage physical findings in infants with chronic or acutely escalating ICP. The unfused sutures provide a compensatory mechanism for the expanding volume, but once separated, it signifies a substantial, long-standing pressure increase.