A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports he will not stop crying even after taking Tylenol with codeine. He also will not straighten the fingers on his right arm. The best response by the nurse is?

A. While skin care is part of overall nursing care, the integumentary system is not the primary concern in Guillain-Barré syndrome (GBS). Pressure injuries may occur if mobility is limited, but deterioration in this system is not life-threatening.

B. Bladder dysfunction can occur in GBS, but it is not usually the most critical system at risk for rapid deterioration. Nursing interventions may include monitoring urinary output and preventing urinary retention, but it is secondary to respiratory monitoring.

C. GBS often causes progressive muscle weakness, including the diaphragm and intercostal muscles, leading to respiratory compromise. The nurse must carefully monitor respiratory status, including respiratory rate, effort, oxygen saturation, and signs of hypoventilation, as respiratory failure is a major complication and can be life-threatening.

D. Cardiovascular complications such as autonomic dysfunction (e.g., fluctuations in blood pressure or heart rate) can occur in GBS, but the immediate priority is respiratory monitoring because respiratory failure can occur rapidly and requires urgent intervention.

A. Minimally invasive surgery is not the standard treatment for plagiocephaly. Surgical intervention is typically reserved for rare, severe, or syndromic cases where conservative measures fail or cranial deformities are extreme. Most infants respond well to non-surgical interventions if identified early.
B. Placing an infant on their back is critical for SIDS prevention, but strict supine positioning can contribute to positional plagiocephaly. Therefore, treatment focuses on repositioning the infant during awake periods, encouraging tummy time, and limiting prolonged supine positioning when the infant is awake and supervised, to promote symmetrical skull growth.
C. Helmet therapy, also called cranial orthosis, is considered the most effective intervention for moderate to severe plagiocephaly. The helmet works by gently guiding skull growth as the infant’s skull is still malleable, usually between 4–12 months of age. Infants typically wear the helmet for 23 hours a day, with adjustments made every few weeks by a specialist to ensure proper fit and effectiveness. This therapy is non-invasive, reduces cranial asymmetry, and avoids the need for surgery in most cases. Parents are also instructed on monitoring skin integrity, proper cleaning, and follow-up appointments to track progress.
D. Hospitalization and surgery are unnecessary for standard positional plagiocephaly. Surgical correction is extremely rare and only indicated for congenital cranial malformations or syndromes that do not respond to conservative management.