A nurse is preparing a 4-year-old child for a tonsillectomy. Which of the following statements should the nurse make?

Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.

Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.

Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.

Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.

Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.

Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.

Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.

Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.