A nurse is admitting a child who has pertussis. Which of the following transmission-based precautions should the nurse initiate?

Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.

Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.

Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.

Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.

Choice A reason: Explaining procedures in detail to the child can be overwhelming and may not be effective, as children with autism spectrum disorder often have difficulty processing too much verbal information at once.

Choice B reason: Staying with the child for long periods of time is not specific to the care of a child with autism spectrum disorder and does not address their unique needs related to transitions or sensory processing.

Choice C reason: Introducing the child to new situations slowly is important because children with autism spectrum disorder may have difficulty with changes in routine or environment. Gradual introduction can help them adjust and reduce anxiety.

Choice D reason: Giving the child three options when making choices can be helpful, but it is not as critical as introducing new situations slowly. Too many choices can sometimes be overwhelming for children with autism spectrum disorder.