A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.
Which of the following actions should the nurse include in the plan of care?

Choice A rationale:

Heart rate is important to monitor but is not specific to the management of cystic fibrosis or the prescribed treatments mentioned in the exhibit. Monitoring heart rate is essential in various clinical situations, but it is not the focus here.

Choice B rationale:

WBC count, or white blood cell count, is a marker of infection or inflammation in the body. While it can be useful in assessing the overall health of a patient, it is not specific to cystic fibrosis or the prescribed treatments mentioned in the exhibit.

Choice C rationale:

HbA1c, or glycated hemoglobin, is a marker used in diabetes management to assess long-term blood sugar control. It is not relevant to cystic fibrosis or the medications prescribed in this case.

Choice D rationale:

Oxygen saturation is a crucial parameter to monitor in a child with cystic fibrosis, especially considering the respiratory complications associated with this condition. Low oxygen saturation levels can indicate respiratory distress, which needs prompt medical attention. Reporting any abnormal oxygen saturation values to the provider ensures timely intervention and appropriate management of the child's respiratory status.

Choice A rationale:

Inserting an IV catheter is essential for administering medications and fluids but is not the immediate priority in this scenario. The toddler's airway and breathing are compromised, making airway management the top priority.

Choice B rationale:

Administering an antibiotic is necessary for treating a potential infection, but securing the airway takes precedence when a child is experiencing severe dyspnea and drooling. The toddler's ability to breathe effectively needs to be addressed urgently.

Choice C rationale:

Obtaining a blood culture is important for identifying the source of infection but does not address the toddler's immediate breathing difficulty. Securing the airway is the primary concern in this situation.

Choice D rationale:

Hyperpyrexia (extremely high fever) along with severe dyspnea and drooling suggests a potentially life-threatening condition like epiglottitis, which requires immediate intervention. Nasotracheal intubation ensures a patent airway, allowing the child to breathe adequately. Once the airway is secure, further assessments and treatments can be administered.