A nurse is planning care for a child who has mumps.
Which of the following instructions should the nurse include in the plan?

The correct answer is Choice A.

Choice A rationale

Placing the child in a knee-chest position helps increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation during a cyanotic spell in children with Tetralogy of Fallot.

Choice B rationale

Having the child lie supine with the head turned to one side does not help in managing a cyanotic spell and may not improve oxygenation.

Choice C rationale

Lying prone does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.

Choice D rationale

Placing the child in a semi-Fowler’s position in an infant seat does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.

Choice A rationale:

Oxygen saturation of 88% on room air is significantly below the normal range (95-100%) and indicates hypoxemia. This finding should be reported to the provider as it may require supplemental oxygen or other interventions.

Choice B rationale:

A heart rate of 128/min is elevated for a school-age child and may indicate increased work of breathing, fever, or other underlying issues. This finding should be reported to the provider for further evaluation.

Choice C rationale:

While the child reporting chest discomfort as 4 on a scale of 0 to 10 is important, it is not as critical as the other findings. The provider should be aware of the discomfort, but it may not require immediate intervention.

Choice D rationale:

An elevated WBC count of 15,000/mm³ indicates an infection, which is consistent with the diagnosis of bilateral pneumonia. While this is important information, it is expected in the context of the current diagnosis and may not require immediate reporting.

Choice E rationale:

Passing three large, frothy, foul-smelling stools is significant in a child with cystic fibrosis as it may indicate malabsorption or other gastrointestinal issues. This finding should be reported to the provider for further evaluation and potential adjustment of the treatment plan.