A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?

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.

Choice A Reason:

Tachypnea is correct .Tachypnea, which refers to rapid breathing, especially when associated with respiratory distress or difficulty in breathing, can be concerning in infants with RSV infection. It could indicate respiratory compromise or worsening of the condition, requiring prompt medical attention and intervention.

Choice B Reason:

Pharyngitis (sore throat) is incorrect. While pharyngitis can be uncomfortable for the infant, it's a common symptom of RSV and may not always indicate an immediate worsening of the condition or respiratory compromise requiring urgent reporting.

Choice C Reason:

Rhinorrhea (runny nose) is incorrect. Similarly, rhinorrhea or a runny nose is a typical symptom of RSV and often occurs in viral respiratory infections without necessarily signaling an immediate need for intervention or urgent reporting.

Choice D Reason:

Coughing is incorrect. Coughing is also a common symptom of RSV and may not always indicate an immediate need for reporting unless it becomes severe or is associated with respiratory distress.