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Outline
A 3-month-old child presents to the emergency room with her mother. The mother reports that the baby is not acting like herself and she is having a hard time arousing the baby. Upon inspection the baby is wrapped in blankets in her car seat sleeping. The nurse unwraps the baby and feels heat radiating off the child.
The vital signs are as follows:
Temp 104°F Rectally
HR 150 bpm
RR 32 bpm
SpO2 99%
BP 66/32 mmHg (54 MAP)
The child is not opening their eyes or crying. The nurse notices the fontanelle is sunken in and the baby’s skin is hot but dry.
What questions should the nurse ask the mother?
- How many wet diapers today?
- Has the mother checked the baby’s temperature? If so, what was it?
- When was the last time baby ate and how much?
- How long has baby been difficult to arouse?
- Has baby produced tears recently?
What are priority nursing actions at this time?
- Get a naked weight on the baby and start calculating fluid replacement for the child.
- Place an IV for fluid resuscitation
- Notify provider of high temperature to get an order for rectal Tylenol
Baby is 5.9 kg and the nurse initiates a peripheral IV for the baby. The provider orders rectal Tylenol at the appropriate weight-based dose.
How much fluids should the baby receive and which vital signs is the most concerning at this time?
- The nurse needs to give a fluid bolus of fluids over 15-30 minutes. The formula for fluid replacement is 20 mL/kg (20 x 5.9). So this baby needs 118 mL of Normal Saline.
- After the initial bolus, a recheck of vitals needs to occur to check hydration status.
- The most concerning vital sign is the temperature of 104° F. The nurse needs to get an order for rectal Tylenol and administer it to the baby then recheck the temperature in 30 minutes.
The baby has received the fluid bolus and rectal Tylenol. The nurse checks another set of vitals and gets the following:
Temp 101 F Rectally
HR 141
RR 30
SpO2 99%
BP 68/42 mmHg (59 MAP)
What should the nurse do next?
- Another bolus of fluids is indicated since the MAP is still not above 60.
- All the vital signs are improving and treatment is proving effective.
- Monitor the temperature and prepare for maintenance fluids once the BP stabilizes.
- Make sure mother doesn’t cover baby with blankets also prepare the child to be admitted to the hospital.
- Major amounts of education needs to be emphasized to mother on signs and symptoms of dehydration, checking baby’s temperature and an eating schedule.
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