A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an antistreptolysin O (ASO) titer. The parent asks the nurse about the purpose of the test. Which of the following responses should the nurse make?

Choice A:In actual practice, log rolling is typically done every 2 hoursto align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT).
as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff
members to assist with log rolling.

Choice B: This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.

Choice C: This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients 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. The nurse should follow standard precautions and surgical site care to prevent infection in this client.

Choice D: This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.

Choice A: An ostomy is a surgical opening in the abdomen that allows stool to pass out of the body. A child who has Hirschsprung disease, which is a condition that causes a blockage of the large intestine due to a lack of nerve cells, may need an ostomy to relieve the obstruction and prevent complications. The ostomy is usually temporary and can be reversed after the affected part of the intestine is removed or repaired. This statement indicates an understanding of the teaching, as the parent knows that the ostomy is not permanent.

Choice B: A urinary catheter is a tube that drains urine from the bladder. A child who has Hirschsprung disease does not need a urinary catheter, as their condition does not affect their urinary system. This statement indicates a lack of understanding of the teaching, as the parent is confused about the type of surgery or device that their child will have.

Choice C: A feeding tube is a tube that delivers nutrition directly into the stomach or small intestine. A child who has Hirschsprung disease may need a feeding tube if they have severe malnutrition, dehydration, or infection due to their condition. However, this is not always necessary and depends on the individual case and the surgeon's preference.
This statement indicates a lack of understanding of the teaching, as the parent assumes that their child will need a feeding tube without knowing the specific plan.

Choice D: A child who has Hirschsprung disease will not have normal bowel movements after the initial surgery, as they will still have an ostomy that bypasses their large intestine. They will need another surgery to reconnect their intestine and restore their bowel function. This statement indicates a lack of understanding of the teaching, as the parent has unrealistic expectations about the outcome of the surgery.