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 B.

Choice A rationale

Obtaining a throat culture is contraindicated in suspected epiglottitis. This procedure can cause further irritation and potentially lead to airway obstruction. Epiglottitis is a medical emergency, and the priority is to maintain a patent airway.

Choice B rationale

Placing the child in an upright position is the correct action. This position helps improve breathing and reduces the risk of airway obstruction. It also allows for better visualization and assessment of the child’s respiratory status.

Choice C rationale

Visualizing the epiglottis with a tongue depressor is not recommended in suspected epiglottitis. This action can cause further irritation and potentially lead to airway obstruction. The priority is to maintain a patent airway and avoid any procedures that could exacerbate the condition.

Choice D rationale

Transporting the child to radiology for a throat x-ray is not the immediate priority. While imaging may be necessary for diagnosis, the primary focus should be on maintaining a patent airway and ensuring the child’s respiratory status is stable.

The correct answer is Choice B.

Choice A rationale

Notifying the health care provider immediately may be necessary if the bleeding is severe or persistent. However, in the case of small amounts of blood, it is important to continue assessing for bleeding to determine if the situation worsens. Immediate notification may not be necessary for minor bleeding.

Choice B rationale

Continuing to assess for bleeding is the best intervention for a child spitting up small amounts of blood after a tonsillectomy. This allows the nurse to monitor the situation and determine if the bleeding is worsening or if it resolves on its own. It is important to keep the child calm and avoid any actions that could exacerbate the bleeding.

Choice C rationale

Encouraging the child to cough can increase the risk of further bleeding. Coughing can dislodge clots and cause additional trauma to the surgical site. It is important to keep the child calm and avoid actions that could worsen the bleeding.

Choice D rationale

Suctioning the back of the throat can cause additional trauma to the surgical site and increase the risk of bleeding. It is important to avoid invasive procedures and continue to assess for bleeding. If the bleeding worsens, further medical intervention may be necessary.