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?

A. "Postpone burping the infant until after completing each feeding."Burping should not be postponed. Infants with a cleft palate may have more difficulty with feeding and may need to be burped more frequently to reduce the risk of aspiration and discomfort.

B. "Feed the infant 177.4 ml. (6 oz) of formula three times each day."The amount and frequency of feeding should be individualized based on the infant's needs and growth patterns. Typically, an infant with a cleft palate requires more frequent, smaller feedings, and the total volume needs to be adjusted according to their specific nutritional needs.

C. "Discontinue a feeding if the infant's eyes become watery."Watery eyes during feeding can be a sign of aspiration or feeding difficulties. If this occurs, it is important to stop the feeding and assess the situation, as it may indicate that the infant is not handling the feeding well and could be at risk for aspiration or other complications.

D. "Elevate the infant's head to a 10° angle during feedings."A 10° angle may be too shallow to effectively prevent aspiration. Typically, the head should be elevated to a greater degree, often 30-45°, to help facilitate safer feeding and reduce the risk of aspiration in infants with a cleft palate.

Choice A Reason:

Administer aspirin for fever is incorrect. Aspirin is contraindicated in children with varicella due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella.

Choice B Reason:

Initiate airborne precautions is correct.Varicella is transmitted via airborne droplets. Use airborne precautions (negative air-flow rooms) for patients with varicella. If negative air-flow rooms are not available, isolate patients in closed rooms with no contact with people without evidence of immunity

Choice C Reason:

Assess the oral cavity for Koplik spots is incorrect. Koplik spots are associated with measles, not varicella. Varicella typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.

Choice D Reason:

Varicella can cause fever and discomfort, and providing a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is more important to initiate airborne precautions.