A nurse is reinforcing discharge instructions with a parent of a 6-year-old child who has just had a tonsillectomy. Which of the following statements by the parent indicates an understanding of postoperative care?

A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.

B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.

C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.

D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.

Increased seizure activity

• Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

• Finding: Cough

A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

• Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

• Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

• Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.