A nurse takes all of these actions when caring for a 13-year-old who just returned from a cardiac catheterization. Which action is incorrect and requires further discussion?

Choice A rationale:

Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.

Choice B rationale:

Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.

Choice C rationale:

Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.

Choice D rationale:

Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.

Choice A rationale:

Placing the infant on her left side with a pillow supporting her back after feeding is appropriate as it prevents aspiration and reflux due to gravity.

Choice B rationale:

Covering the cast with a towel to prevent accidental soiling is a sensible action, ensuring the cast remains clean and dry.

Choice C rationale:

The mother using the football hold to position the infant securely to one side might hinder the cast's stability and could potentially cause discomfort or displacement.

Choice D rationale:

Supporting both the infant's head and cast when leaning her forward for burping is essential to maintain the cast's integrity and to prevent strain on the infant's body.