A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.

Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. "Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.

B. "Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.

C. "Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.

D. "Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.

Initiating airborne precautions. The child’s symptoms (fever, headache, nausea, lethargy, irritability, nuchal rigidity, and elevated WBC count) suggest bacterial or viral meningitis, which requires airborne precautions if tuberculosis or certain viral causes are suspected.

WBC. The child's WBC count is elevated (14,000 mm³), indicating a possible infection, which supports the need for precautions to prevent transmission.

Administering potassium chloride. The child's potassium level (3.8 mEq/L) is within the normal range (3.4-4.7 mEq/L), so potassium replacement is unnecessary.

Pain level. While pain management is important, it does not directly relate to the need for airborne precautions.

Administering acyclovir. Acyclovir is an antiviral used to treat herpes infections, but there is no indication in the scenario that the child has a viral infection requiring acyclovir.

Lymph node findings. While cervical lymphadenopathy can occur with infections, it does not necessarily indicate the need for acyclovir.

Increasing environmental stimuli. The child is already lethargic and irritable, so reducing stimuli (not increasing) would be more appropriate.

Potassium level. The potassium level is normal and does not indicate a need for intervention.