A 12-year-old child is being admitted to the pediatric unit. What is the priority nursing action based on these the data below? Vital signs: T: 104F (40C) P: 89, R: 30, B/P: 80/42 Nurse's notes: Difficult to arouse, c/o headache, emesis x2, exhibiting nuchal rigidity, slight petechiae noted on distal extremities, lumbar puncture completed with results of elevated WBCs in CSF, decreased glucose in CSF.

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence. B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition. C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals. D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.