As a nurse, what will be your first action if a mother complains of an increased body temperature of her 2-day-old newborn baby? The body temperature by axilla is 100.6°F.

Appeared in: ISRO 2024

Explanation

The first step in the nursing process is assessment. Before intervening, the nurse must gather data to determine the cause of the fever.
In a 2-day-old newborn, a mild fever is frequently caused by dehydration ('dehydration fever') due to insufficient fluid intake as breastfeeding is being established.
Assessing the feeding pattern directly investigates the most common and easily reversible cause of mild hyperthermia in this age group.
This action is non-invasive, safe, and addresses the likely root cause before escalating to medication or other interventions.

Option A: Administering medication is an intervention, not an assessment. It is not the first action, as it masks the symptom without identifying the underlying cause, which is likely dehydration.
Option C: Tepid sponging is generally contraindicated in newborns because it can induce shivering and cold stress, leading to an increased metabolic rate and potential hypothermia, which is dangerous for a neonate.
Option D: While communication with the pediatrician is important, a nurse's primary responsibility is to perform an initial assessment to gather data. Informing the doctor without any assessment findings (like feeding history or other symptoms) is an incomplete report.

Clinical Relevance

Nursing practice connection: Knowing Neonatal Thermoregulation and Prioritization of Nursing Actions helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
A key nursing role is educating new mothers about newborn care, including recognizing signs of adequate feeding and hydration.
Prioritizing assessment over intervention prevents unnecessary medication use and potentially harmful procedures like tepid sponging in vulnerable newborns.
Patient safety is paramount. Rushing to intervene without assessment can miss the simple, underlying cause and may even cause harm (e.g., cold stress from sponging).

How to Approach the Question

First, identify the patient population: a 2-day-old newborn. This is a critical detail as their physiology is unique.
Next, note the clinical finding: an increased temperature of 100.6°F, which is a mild fever.
The question asks for the 'first action'. This signals a priority-setting question. Recall the steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE). Assessment is always the first step.
Evaluate the options in the context of the nursing process and the patient's specific needs.
Option B ('Assess the feeding pattern') is an assessment. Options A and C are interventions. Option D is an escalation/reporting action.
Considering the common causes of mild fever in a newborn (dehydration), the assessment option that targets this cause is the most logical and appropriate first step.

Concept Tested & Keywords

Concept Tested: Neonatal Thermoregulation and Prioritization of Nursing Actions
Stem keywords: nurse, first action, mother complains, increased body temperature, 2-day-old newborn, 100.6°F
Lead-in keywords: first action
Clinical cues: Patient is a 2-day-old newborn, a population with unique physiological characteristics.
Clinical cues: The temperature is a mild elevation (100.6°F), not a high-grade fever, which influences the urgency and type of intervention.

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E6 Ghai Essential Pediatrics(pp 26-904 of 913) pp. 221-223, 138-140

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 1064-1066

Practise the full ISRO 2024

Attempt every question from this paper in a timed mock, then review the full solution for each one.