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?

The correct answer is choice b. Stretch the perineum taut when applying the bag.

Choice A rationale:

Positioning the opening of the bag over both the urethra and the anus is incorrect because it increases the risk of contamination from fecal matter, which can lead to inaccurate test results.

Choice B rationale:

Stretching the perineum taut when applying the bag ensures a secure fit and reduces the risk of leakage, which is essential for accurate urine collection.

Choice C rationale:

Applying lidocaine gel to the perineum before attaching the bag is not recommended as it is unnecessary and could cause irritation or an allergic reaction in the infant.

Choice D rationale:

Placing a snug-fitting diaper over the drainage bag is not the correct action because it can cause the bag to become dislodged or compressed, leading to inaccurate collection or spillage.

Choice A rationale:

Allowing the child to adjust their bedtime might promote autonomy, but in a hospital setting, routine and familiarity are essential for reducing anxiety in school-age children. Disrupting their home sleep routine may increase stress and hinder the child's ability to rest properly.

Choice B rationale:

Leaving the lights on in the child's room contradicts the principles of creating a sleep-conducive environment. Adequate sleep hygiene involves a dark and quiet room. Leaving lights on could interfere with the child's ability to fall asleep, potentially leading to sleep disturbances and increased anxiety.

Choice C rationale:

Following the child's home sleep routine is the most appropriate intervention. Maintaining consistency with the child's usual bedtime routine provides a sense of familiarity and security, reducing anxiety and promoting better sleep. This approach aligns with the principles of pediatric nursing, ensuring the child's emotional well-being while in the hospital.

Choice D rationale:

Providing the child with video games prior to bedtime is not recommended, especially in a hospital setting. Screen time, especially before sleep, can disrupt sleep patterns due to the blue light emitted by electronic devices. Additionally, video games may stimulate the child, making it harder for them to relax and fall asleep. This choice can exacerbate the child's stress and hinder their ability to achieve adequate sleep.