A swollen joint.

The practical nurse (PN) is caring for a 20-month-old toddler who was admitted with a sickle cell crisis.

The mother rocks the toddler who continues to cry, is restless, and does not wish to be touched.

The electronic monitoring device indicates that the toddler's temperature is 102° F (38.8° C), heart rate is 140 beats/minute, blood pressure 122/70 mm Hg, and oxygen saturation 98%. Which problem(s) should the PN document as the priority in the client's plan of care (POC)? Select all that apply.

Choice A rationale

Administering ibuprofen, an NSAID, can alleviate pain by inhibiting prostaglandin synthesis, reducing inflammation. However, increased pain and pressure postpartum, especially with a laceration, could indicate complications like a hematoma. Normal pain is expected, but increasing pain warrants further assessment, as it could mask a worsening condition and delay necessary intervention.

Choice B rationale

Increased pain and pressure postpartum after a vaginal delivery, especially with a second-degree perineal laceration, could signal a perineal hematoma. This condition involves blood accumulation in the tissue, causing significant pain and pressure. Notifying the healthcare provider is crucial for immediate assessment, diagnosis, and potential intervention to prevent further complications.

Choice C rationale

Applying an ice pack to the perineum is a common intervention for pain and swelling after a vaginal delivery and laceration repair. Cold therapy induces vasoconstriction, which reduces blood flow to the area, thereby minimizing edema and inflammation. This can provide localized pain relief, but for increasing pain, it might only offer symptomatic relief without addressing the underlying cause.

Choice D rationale

Routine perineal care, including cleansing and hygiene, is essential for preventing infection and promoting healing after a vaginal delivery and laceration. It helps remove lochia and bacteria, maintaining a clean environment. While crucial for recovery, routine care does not directly address or alleviate increasing pain and pressure that could indicate a complication like a hematoma.

Choice A rationale

Placing an infant on their back for naps is a critical recommendation to reduce the risk of Sudden Infant Death Syndrome (SIDS), but it is not directly related to managing bronchiolitis symptoms or preventing its spread. While generally good advice, it doesn't address the acute respiratory infection.

Choice B rationale

Encouraging the infant to play might be detrimental during an acute febrile illness like bronchiolitis. Increased physical activity can increase oxygen demand and exacerbate respiratory distress in an infant whose respiratory system is already compromised, potentially worsening their clinical condition.

Choice C rationale

Limiting intake of oral fluids would be counterproductive for an infant with bronchiolitis and fever. Adequate hydration is crucial to thin respiratory secretions, facilitate expectoration, and prevent dehydration, especially with fever, which increases insensible fluid losses. Maintaining hydration supports recovery.

Choice D rationale

Isolating the infant from others is a crucial measure to prevent the spread of respiratory syncytial virus (RSV), the most common cause of bronchiolitis, to susceptible individuals. RSV is highly contagious, and isolation helps protect other children and adults, particularly those with compromised immune systems.