A nurse is assessing a child who has measles.
Which of the following areas should the nurse inspect for Koplik spots?

The correct answer is Choice C.

Choice A rationale

Restricting the child’s strenuous activities for 3 days is important, but it is not the priority. Monitoring for signs of impaired circulation or complications is more critical.

Choice B rationale

Using a hair dryer on a cool setting to relieve itching can be helpful, but it is not the priority. The priority is to monitor for signs of impaired circulation.

Choice C rationale

Monitoring for pallor or swelling in the child’s affected hand is the priority because it can indicate impaired circulation or compartment syndrome, which are serious complications that require immediate attention.

Choice D rationale

Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications. .

The correct answer is Choice B.

Choice A rationale

Serous chest tube drainage is a normal finding and does not typically indicate a complication. It is usually clear or pale yellow fluid that is expected after surgery.

Choice B rationale

Chest tube drainage of 200 mL in 1 hour is excessive and should be reported to the provider. This could indicate active bleeding or other complications that require immediate attention.

Choice C rationale

Fluctuation in the water-sealed chamber, also known as tidaling, is a normal finding and indicates that the chest tube is functioning properly. It reflects changes in pressure within the pleural space during respiration.

Choice D rationale

A respiratory rate of 22/min is within the normal range for a school-age child and does not typically indicate a complication.