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 according to the nursing process (ADPIE), is always assessment.
• A low-grade fever in a 2-day-old newborn is a classic sign of 'dehydration fever' or 'inanition fever' (SRC_19726, SRC_19728).
• This type of fever is caused by insufficient fluid intake as the mother's milk supply is not yet fully established.
• Therefore, assessing the feeding pattern (frequency, duration, latch, milk transfer) is the most logical and critical first step to identify and address the root cause.
• Correcting the fluid deficit by improving feeding is often sufficient to resolve the fever, avoiding unnecessary medical interventions.

Why Other Options Were Wrong

• Option A: This is an intervention that requires a physician's order and should not be the first action. The underlying cause of the fever must be identified before administering medication.
• Option C: Tepid sponging is contraindicated in newborns. It can cause rapid and uncontrolled heat loss, leading to cold stress, increased metabolic rate, increased oxygen consumption, and potentially severe hypothermia (SRC_19728).
• Option D: This is a reporting action, not an assessment or initial intervention. A nurse must first assess the patient to gather relevant data to report to the physician. Reporting without assessment is incomplete nursing care.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Nursing management of neonatal hyperthermia and application of the nursing process helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• This scenario highlights the critical nursing principle of 'assess before you act.' Rushing to an intervention without understanding the cause can be ineffective and potentially harmful.
• Nurses are pivotal in providing lactation support and education to new mothers. Identifying and correcting feeding issues early can prevent common problems like dehydration fever and excessive weight loss.
• Patient safety is paramount. Understanding contraindications, such as tepid sponging in newborns, is essential to prevent iatrogenic harm.

How to Approach the Question

• First, identify the keywords in the question: 'first action', 'new born baby', '2 days old', and '100.6°F'.
• Recognize that 'first action' questions often test knowledge of the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation). Assessment is the initial step.
• Analyze the clinical context: A 2-day-old with a low-grade fever. Recall common physiological occurrences in this specific timeframe, such as dehydration fever.
• Evaluate the options in the context of the nursing process and safety. 'Assess the feeding pattern' is the only assessment option.
• Eliminate the intervention options ('Administer paracetamol', 'Do tepid sponging') as premature actions. Tepid sponging is also unsafe.
• Consider the reporting option ('Inform pediatrician'). While necessary, it should follow the initial nursing assessment to provide a complete clinical picture. Therefore, assessing feeding is the most appropriate first action.

Concept Tested & Keywords

• Concept Tested: Nursing management of neonatal hyperthermia and application of the nursing process.
• Stem keywords: nurse, first action, new born baby, 2 days old, increased body temperature, 100.6° Fahrenheit
• Lead-in keywords: first action
• Clinical cues: Age of 2 days old: This is a key period for the onset of dehydration fever as lactation is established.
• Clinical cues: Temperature of 100.6°F: This is a low-grade fever, making an urgent infectious cause less likely than a physiological one like dehydration.

Question ID

Qi1vPTIudXAE3GY0Zkp--x

Copy ID

Reference Book

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