A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which action is the nurse's priority?

A. “My child will take the enzymes following meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not after, to help with the digestion of food.
B. “My child will take the enzymes 2 hours before meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not before, to help with the digestion of food.
C. “My child will take the enzymes to improve her metabolism.”: While pancreatic enzymes do aid in digestion, which is a part of metabolism, this statement is not specific enough to indicate a correct understanding of the purpose of the enzymes.
D. “My child will take the enzymes to help digest the fat in foods.”: This is the correct answer. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food, aiding in their digestion and absorption in the intestines. This is particularly important in conditions like cystic fibrosis, where the pancreas does not produce enough of these enzymes naturally.

Answer: D. Maintains a dry dressing over the sac

A. Places the infant in a side-lying position.
Placing the infant in a side-lying position is not the most appropriate action for a child with myelomeningocele. It is often recommended to position infants in a supine (on their back) or prone (on their stomach) position to prevent pressure on the sac and facilitate optimal positioning for spinal alignment and care.

B. Takes an axillary temperature.
While taking an axillary temperature is a common practice for infants, it is not specific to the care of an infant with myelomeningocele. In fact, rectal temperatures are often preferred in clinical settings for more accurate readings in infants, particularly if there are concerns about infection or significant illness.

C. Performs range of motion on the infant's hips.
Performing range of motion exercises on the infant's hips may be appropriate for some infants but should be done cautiously in those with myelomeningocele. Depending on the extent of nerve damage, the infant may have limited mobility or lack sensation in the lower extremities, and inappropriate exercises could risk injury or further complications.

D. Maintains a dry dressing over the sac.
Maintaining a dry dressing over the sac is a critical action in the care of an infant with myelomeningocele. This condition involves a defect in the spinal column where the spinal cord and surrounding nerves protrude through the back, making the area susceptible to infection and injury. Keeping the dressing dry and intact protects the sac and prevents infection, indicating that the newly licensed nurse understands the importance of this essential nursing intervention.