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 C.

Choice A rationale

The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.

Choice B rationale

The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.

Choice C rationale

The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.

Choice D rationale

The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.

The correct answer is Choice D.

Choice A rationale

Erikson’s stage of initiative versus guilt occurs in preschool-aged children (3-5 years), not toddlers.

Choice B rationale

Imaginary playmates are more common in preschool-aged children and are not a characteristic of toddlerhood.

Choice C rationale

Demonstrations of sexual curiosity are more common in preschool-aged children and are not a characteristic of toddlerhood.

Choice D rationale

Negative behaviors characterized by the need for autonomy are typical in toddlers. This stage, according to Erikson, is autonomy versus shame and doubt, where toddlers strive for independence and self-control.