A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Choice A: Contact isolation is not appropriate for a child who has measles, which is a highly contagious viral infection that causes fever, rash, cough, runny nose, and red eyes. Contact isolation is used for patients who have infections that can be spread by direct or indirect contact with the patient or their environment, such as wound infections, scabies, or Clostridioides difficile. Contact isolation requires wearing gloves and gowns and using dedicated equipment.

Choice B: Airborne isolation is appropriate for a child who has measles, as it is used for patients who have infections that can be spread by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. Airborne isolation requires wearing a respirator mask and placing the patient in a negative pressure room with the door closed.

Choice C: Protective environment isolation is not appropriate for a child who has measles, as it is used for patients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. Protective environment isolation requires wearing gloves, gowns, masks, and eye protection and placing the patient in a positive pressure room with high-efficiency particulate air (HEPA) filters.

Choice D: Droplet isolation is not appropriate for a child who has measles, as it is used for patients who have infections that can be spread by large droplets that can travel up to 6 feet from the source, such as influenza, pertussis, or meningitis. Droplet isolation requires wearing a surgical mask and eye protection and placing the patient in a private room or cohorting with other patients with the same infection.

Choice A reason: This choice is correct because providing a latex-free environment is an essential intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Spina bifida is a congenital defect in which the spinal cord and its coverings do not close properly, resulting in a protrusion of the meninges (meningocele) or the meninges and spinal cord (myelomeningocele). Children who have spina bifida are at a high risk of developing a latex allergy, which can cause severe reactions such as anaphylaxis or death. Therefore, avoiding exposure to latex products such as gloves, catheters, balloons, or bandages is crucial to prevent complications.

Choice B reason: This choice is incorrect because initiating contact precautions is not necessary for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Contact precautions are infection control measures that prevent the transmission of microorganisms that can be spread by direct or indirect contact with the client or their environment. They may be indicated for clients who have multidrug-resistant organisms, clostridium difficile, or scabies, but they are not required for clients who have spina bifida unless they have a concurrent infection.

Choice C reason: This choice is incorrect because limiting visitors to immediate family members is not indicated for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Limiting visitors may be indicated for clients who have immunosuppression, isolation, or terminal illness, but it may not be beneficial for clients who have spina bifida. Allowing visitors may provide emotional and social support for the client and their family, as long as they follow standard precautions and do not pose any risk of infection or injury.

Choice D reason: This choice is incorrect because maintaining the infant in the supine position is not an appropriate intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac.
Maintaining the infant in the supine position may cause pressure or trauma to the sac, which can lead to rupture, infection, or nerve damage. Therefore, positioning the infant in a prone or side-lying position with the hips flexed and knees abducted can help to protect the sac and prevent complications.