A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?

A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.

B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.

C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.

D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.

A. Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.

B. While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.

C. This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).

D. Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.