A nurse is admitting an 8-year-old child to the pediatric unit. A nurse is reviewing the child's electronic medical record (EMR). Which of the following findings should the nurse identify as requiring immediate follow-up? Select the 5 findings that require immediate follow-up.
Explanation & Rationale
A. Abdominal assessment: While assessing the abdomen is important in a pediatric admission, there are currently no signs of abdominal distress, vomiting, or pain that are life-threatening. It should be monitored, but it does not require immediate follow-up compared with the other acute findings. B. Glucose: The child’s glucose level is 90 mg/dL, which falls within normal limits for an 8-year-old. Immediate follow-up is not necessary unless clinical signs suggest hypoglycemia or hyperglycemia. C. Temperature: The child has a fever of 38.7° C (101.7° F), which, combined with irritability, nuchal rigidity, and recent upper respiratory infection, could indicate a serious infection such as meningitis. Immediate follow-up is warranted to prevent complications and initiate treatment. D. Pain assessment: The child reports severe headache rated 7/10 and exhibits irritability and lethargy. These neurological symptoms in combination with fever and nuchal rigidity indicate a potential emergent condition and require immediate evaluation. E. Hemoglobin: Hemoglobin is 9.5 g/dL, which is below normal for an 8-year-old. While this is not immediately life-threatening, it requires prompt attention to determine cause, especially if the child shows fatigue or signs of decreased oxygen delivery. F. WBC: The WBC count is 14,000/mm³, indicating leukocytosis and possible systemic infection. This finding requires immediate follow-up to guide diagnosis and treatment decisions, particularly in the context of fever and nuchal rigidity. G. Neurologic assessment: The child is lethargic, irritable, and has nuchal rigidity. These are signs of possible central nervous system involvement, such as meningitis or encephalitis, requiring urgent evaluation. H. Peripheral pulses: Peripheral pulses are not noted as abnormal, and there is no indication of cardiovascular compromise. Immediate follow-up is not required unless clinical changes occur.