A nurse is triaging a 4-year-old child with high fever, drooling, difficulty swallowing, muffled voice, and the child is leaning forward in a tripod position. Which action is the highest priority?
- A.Obtain a throat culture by swabbing the posterior pharynx
- B.Administer acetaminophen for fever and reassess in 30 minutes
- C.Do not examine the throat; activate rapid response and prepare for emergency airway management
- D.Place the child supine and obtain a chest X-ray
Show answer & rationale
Correct answer
C. Do not examine the throat; activate rapid response and prepare for emergency airway management
Rationale
C is correct: This presentation, high fever, drooling, dysphagia, muffled voice, and tripod positioning in a young child, is classic for epiglottitis, a life-threatening airway emergency. Any attempt to examine the throat or disturb the child could trigger laryngospasm and complete airway obstruction. The child must be kept calm and upright, a rapid response team activated, and the team prepared for intubation or emergency tracheostomy. A is incorrect: Attempting to swab the posterior pharynx could precipitate complete airway obstruction in epiglottitis. This is a contraindicated action. B is incorrect: Fever management is supportive but does not address the airway emergency. A 30-minute reassessment delay is dangerous. D is incorrect: Placing the child supine removes the compensatory effect of gravity and tripod positioning, which helps maintain the airway; this could cause complete obstruction.
Key concepts