The nurse identifies the nursing diagnosis of risk for infection related to chemotherapy-induced immunosuppression. What would the nurse include in the teaching plan for the child and parents about reducing the child's risk?

A. While skin care is part of overall nursing care, the integumentary system is not the primary concern in Guillain-Barré syndrome (GBS). Pressure injuries may occur if mobility is limited, but deterioration in this system is not life-threatening.

B. Bladder dysfunction can occur in GBS, but it is not usually the most critical system at risk for rapid deterioration. Nursing interventions may include monitoring urinary output and preventing urinary retention, but it is secondary to respiratory monitoring.

C. GBS often causes progressive muscle weakness, including the diaphragm and intercostal muscles, leading to respiratory compromise. The nurse must carefully monitor respiratory status, including respiratory rate, effort, oxygen saturation, and signs of hypoventilation, as respiratory failure is a major complication and can be life-threatening.

D. Cardiovascular complications such as autonomic dysfunction (e.g., fluctuations in blood pressure or heart rate) can occur in GBS, but the immediate priority is respiratory monitoring because respiratory failure can occur rapidly and requires urgent intervention.

A. Newborns typically exhibit a degree of physiological hypotonia, meaning their muscles are naturally a bit “floppy” due to immature neuromuscular development. Hypotonia in this context is expected and normal; therefore, the absence of hypotonia (meaning the baby has normal or increased muscle tone) is not abnormal. It suggests that muscle tone is within expected limits and does not indicate pathology.

B. A normal newborn should have full and symmetric passive range of motion in all joints without resistance or stiffness. This finding indicates that the musculoskeletal system is developing appropriately. Limitations in movement, joint contractures, or asymmetry would be considered abnormal, but full range of motion is normal.

C. Deep tendon reflexes in a newborn are expected to be brisk or moderately active due to the immature but intact nervous system. Sluggish or absent reflexes can indicate several potential problems: Peripheral nervous system dysfunction, such as peripheral neuropathy or spinal cord injury. Central nervous system abnormalities, including hypoxic-ischemic encephalopathy, brain or spinal cord malformations, or developmental delays. Metabolic or systemic disorders, such as hypothyroidism or electrolyte imbalances, which can affect neuromuscular function. Sluggish reflexes are therefore an abnormal finding and warrant further evaluation.

D. Mild eye wandering in newborns is common and considered a normal part of ocular development. At birth, infants’ eye muscles are not fully coordinated, so they may appear crossed or wander intermittently. This usually resolves by 3–4 months of age as visual tracking and extraocular muscle control mature. Persistent or severe strabismus later than 4–6 months would be abnormal, but in the immediate newborn period, this is typical.