As a nurse what will be your first action if mother complains of increased body temperature of her new born baby of 2 days old. Body temperature by axilla is 100.6° Fahrenheit?

1. A

   Administer paracetamol drops

2. B

   Assess the feeding pattern

3. C

   Do the tepid sponging

4. D

   Inform pediatrician

Appeared in: BHU NO - 12 April 2024

Explanation

• The question asks for the nurse's first action, which prioritizes assessment over intervention according to the nursing process.
• A low-grade fever (100.6°F) in a 2-day-old newborn is frequently caused by dehydration fever (inanition fever).
• This type of fever occurs due to insufficient fluid intake while the mother's milk supply is being established.
• Assessing the feeding pattern (frequency, latch, duration, number of wet diapers) is the most direct way to evaluate the newborn's hydration status and identify the likely cause of the fever.
• Addressing inadequate feeding is a simple, non-invasive intervention that can resolve the fever.

Why Other Options Were Wrong

• Option A: Administering medication is an intervention, not a first-line assessment. It requires a physician's order and masks the fever, which is an important clinical sign.
• Option C: Tepid sponging is contraindicated in newborns. It can cause rapid heat loss, leading to cold stress, increased metabolic rate, and dangerous hypothermia.
• Option D: While the pediatrician should be kept informed, the nurse's role is to first assess the patient to gather necessary data. Reporting without assessment is incomplete and not the best practice.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Initial nursing management of neonatal fever helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• This scenario emphasizes the core nursing principle: 'Assess before you act.' A thorough assessment prevents unnecessary or harmful interventions.
• Recognizing dehydration fever is a key competency in neonatal nursing, preventing unnecessary workups for sepsis and promoting breastfeeding success.
• Patient safety is paramount. Avoiding contraindicated procedures like tepid sponging in newborns prevents iatrogenic complications like cold stress.

How to Approach the Question

• First, identify the question type. This is a 'priority' question, asking for the 'first action'.
• Analyze the patient details: a 2-day-old newborn. This age is critical for identifying common physiological issues.
• Note the clinical finding: a low-grade fever of 100.6°F axillary.
• Apply the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation). Assessment always comes first.
• Evaluate the options: 'Assess the feeding pattern' is the only assessment. The other options are interventions (administering medication, sponging) or escalation (informing the doctor).
• Rule out interventions as the first step. Choose the most relevant assessment based on the patient's age and condition. In this case, assessing for dehydration is the most logical first step.

Concept Tested & Keywords

• Concept Tested: Initial nursing management of neonatal fever.
• Stem keywords: nurse, first action, new born, 2 days old, increased body temperature, 100.6° Fahrenheit
• Lead-in keywords: first action
• Clinical cues: The newborn's age of 2 days is a critical cue, pointing towards common physiological issues like dehydration fever as breastfeeding is established.

Question ID

Qi1vPTIudXAE3GY0Zkp--x

Copy ID

Reference Book

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 221-223

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