The nurse is caring for a child and notes periorbital edema and urticaria.
Which action by the nurse is priority?

Choice A rationale

Mumps is a viral infection caused by a paramyxovirus, primarily characterized by painful swelling of the parotid salivary glands, leading to pain on chewing or near the earlobe. In post-pubertal males, like this 15-year-old, mumps can also cause orchitis, which is the inflammation and swelling of one or both testes, perfectly aligning with the client's symptoms. The general symptoms of fever, headache, and malaise are also typical of the prodromal phase of mumps infection.

Choice B rationale

Poliomyelitis, caused by the poliovirus, primarily affects the central nervous system, leading to muscle weakness and paralysis, particularly in the lower limbs. While it can cause non-specific symptoms like fever and headache, it does not typically cause parotid gland swelling (parotitis) or testicular swelling (orchitis), making this diagnosis inconsistent with the client's constellation of specific findings.

Choice C rationale

Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is commonly known as the "kissing disease" and typically presents with a classic triad of fever, pharyngitis (sore throat), and lymphadenopathy (swollen lymph nodes). Although it can cause generalized malaise, it does not characteristically cause parotid swelling or orchitis, which are key features in this client's presentation.

Choice D rationale

Herpes zoster, or shingles, is caused by the reactivation of the varicella-zoster virus (VZV) and manifests as a painful, blistering rash typically confined to a dermatome, or specific sensory nerve distribution. It rarely presents only with fever, headache, malaise, parotitis, and orchitis without a dermatomal rash, making this an unlikely diagnosis for these symptoms.

Choice A rationale

Digoxin is a cardiac glycoside that slows and strengthens the heart rate and is commonly used in infants with heart failure. For an infant, the normal apical pulse rate typically ranges from 100 to 160 beats per minute. A rate of 80 beats per minute is significantly below the acceptable lower limit, indicating potential digoxin toxicity or an existing underlying bradycardia, requiring the nurse to hold the dose and notify the physician immediately to prevent serious adverse effects.

Choice B rationale

A heart rate of 140 beats per minute is within the normal physiological range for an infant, which is generally 100 to 160 beats per minute. This rate is considered acceptable and does not warrant holding the prescribed dose of digoxin, assuming other parameters and clinical signs of toxicity are absent. Digoxin aims to improve cardiac contractility and may slightly slow the rate but 140 is a safe rate.

Choice C rationale

An apical pulse rate of 100 beats per minute sits at the lower boundary of the normal range for an infant, which spans from 100 to 160 beats per minute. While close to the cutoff, it is still technically acceptable for administering digoxin. The nurse would monitor closely, but the dose would generally not be withheld unless the rate was less than 90 or 100, depending on the facility policy.

Choice D rationale

A heart rate of 120 beats per minute is well within the expected and safe normal range for an infant, which typically extends from 100 to 160 beats per minute. This rate is adequate and does not suggest bradycardia or pose any immediate concern regarding digoxin administration. The dose should be given as scheduled, and continued monitoring should take place.