A nurse is caring for a 6-month-old infant with a fever of 103.1°F (39.5°C). The infant appears restless and irritable. Which nursing intervention should the nurse implement first?

Removing excess clothing and blankets is the first priority for a febrile child as it allows immediate heat dissipation through radiation and convection. Other interventions like antipyretics, fluids, and cool compresses are important but should follow this initial non-pharmacological cooling measure.

Clinical Reasoning and Priority Setting

When an infant presents with a high fever of 103.1°F (39.5°C) accompanied by restlessness and irritability, the nurse must rapidly identify the safest and most immediate intervention. The correct first action is to remove excess clothing and blankets.

The physiological principle guiding this decision is the mechanism of heat dissipation. Infants have an immature thermoregulatory system and a high body surface area-to-weight ratio, making them highly susceptible to external environmental temperatures. Bundling an infant in heavy clothing or blankets traps heat, preventing conduction and convection—the passive loss of body heat to the surrounding air and surfaces. By removing these external insulators, the nurse facilitates the body’s natural cooling process, which can rapidly reduce the temperature and alleviate the infant’s irritability without the risk of pharmacological side effects. This aligns with foundational fever management principles, where physical cooling measures are prioritized to prevent a further rise in core temperature and reduce metabolic demand.

While the other options are important components of fever management, they are not the correct first intervention. Administering acetaminophen (Option 1) requires a confirmed order and time to take effect; it does not address the immediate heat retention caused by over-bundling. Encouraging increased fluid intake (Option 3) is crucial to prevent dehydration from insensible water loss, but it is a secondary measure that does not directly lower the body temperature. Applying cool compresses (Option 4) can cause peripheral vasoconstriction and shivering if not done carefully, which paradoxically raises core temperature and increases discomfort. Therefore, the least invasive, most immediate method to promote heat loss is to uncover the infant.

This prioritization is supported by research on parental fever management behaviors. A study examining the relationship between digital health literacy and fever management in children found that effective fever management is built upon a foundation of accurate knowledge and self-efficacy in applying basic physical care measures . The study highlights that appropriate initial responses, such as adjusting the child's environment, are key components of the Parent Fever Management Scale, reflecting evidence-based practices that nurses must model and teach. By first removing excess clothing, the nurse not only intervenes correctly but also demonstrates a critical, non-pharmacological technique that caregivers can safely replicate at home .