A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?

Choice A reason: Assessing the client's erythematous rash is an important action for the nurse to take, but it is not the priority. The rash is one of the minor criteria for diagnosing acute rheumatic fever, and it may not be present in all cases. The rash is usually non-pruritic and migratory, and it appears on the trunk and extremities.

Choice B reason: Identifying the degree of parental anxiety related to the diagnosis is an appropriate action for the nurse to take, but it is not the priority. The nurse should provide emotional support and education to the parents, and address their concerns and questions. However, this is not the most urgent action.

Choice C reason: Auscultating the rate and characteristics of the child's heart sounds is the priority action for the nurse to take, as it can detect the presence and severity of carditis, which is the most serious complication of acute rheumatic fever. Carditis is the inflammation of the heart muscle, valves, or pericardium, and it can cause murmurs, tachycardia, dysrhythmias, heart failure, or death.

Choice D reason: Using a pain-rating tool to determine the severity of the joint pain is an important action for the nurse to take, but it is not the priority. The joint pain is one of the major criteria for diagnosing acute rheumatic fever, and it is usually severe and migratory, affecting the large joints such as the knees, ankles, elbows, or wrists. The nurse should assess the pain level and provide analgesics and anti-inflammatory medications as prescribed.

Choice A reason: Elbow restraints are commonly used for infants who have undergone cleft lip and palate repair to prevent them from touching or rubbing their incisions, which could cause bleeding, infection, or disruption of the sutures¹².

Choice B reason: Wrist restraints are not appropriate for infants who have undergone cleft lip and palate repair because they do not prevent the infant from reaching their mouth with their fingers or objects. Wrist restraints are more suitable for older children or adults who need to avoid pulling out tubes or catheters³.

Choice C reason: Jacket restraints are not indicated for infants who have undergone cleft lip and palate repair because they do not restrict the movement of the arms or hands. Jacket restraints are more useful for children who need to be secured to a bed or chair to prevent falls or injuries³.

Choice D reason: Mummy restraints are not recommended for infants who have undergone cleft lip and palate repair because they immobilize the entire body and can cause respiratory distress, overheating, or skin breakdown. Mummy restraints are only used for short procedures that require minimal movement, such as venipuncture or lumbar puncture³.