A mother brought her 8 year old into the emergency room because although she was fine when she woke up this morning, she now has a fever of 39.8 C, cannot speak, is drooling, and is tachypneic and stridorous
Her pulse oximetry reading is 90 percent on a rebreather mask. What would be the next appropriate nursing action? 1. Suction her mouth, then conduct throat and blood cultures as well as a test for gram positive bacteria.
2. Prepare the child and mother for an MRI scan to evaluate for a "thumb sign.".
3. Monitor respiratory status closely, prepare for intubation, and keep the child calm to avoid crying.
4. Suction her mouth, monitor respiratory status closely, and give a Palivizumab injection.
3
Feedback
1. Suctioning can cause more traumas to the area.
2. The "thumb sign" will not occur in this condition.
3. The nurse would monitor and be prepared for possible rapid decline in respiratory status and try to keep the child from crying.
4. Suctioning the mouth can cause more damage, and the injection should not be given at this time.
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