A nurse is assessing the fontanels of an 8-month-old infant.
Which of the following findings should the nurse recognize as an expected finding?

The correct answer is Choice B: Assign the child to a negative air pressure room.

Choice A rationale: Assessing the child for Koplik spots is not appropriate in this situation because Koplik spots are associated with measles, not varicella. Koplik spots are small, white, irregular lesions that appear on the buccal mucosa during the prodromal phase of measles. They do not present in cases of varicella, which is characterized by a pruritic, vesicular rash.

Choice B rationale: Assigning the child to a negative air pressure room is the most suitable action because varicella is highly contagious and can be transmitted through airborne particles. A negative air pressure room helps to contain these particles and minimize the risk of infection transmission to other patients, healthcare workers, and visitors. Airborne precautions are the recommended infection control measures for managing varicella cases in healthcare settings.

Choice C rationale: Utilizing droplet precautions alone is insufficient for managing varicella because the virus can also be spread through airborne particles. While droplet precautions may be a component of the overall infection control strategy, they are inadequate without the additional implementation of airborne precautions, such as a negative air pressure room.

Choice D rationale: Administering aspirin to a child with a viral illness is generally contraindicated due to the potential risk of Reye's syndrome, a rare but severe condition characterized by liver failure and encephalopathy. It is essential to follow appropriate guidelines for managing fever and discomfort in pediatric patients with varicella, which typically involve using acetaminophen or ibuprofen instead of aspirin.

The correct answer is choice A, B, D, and F.

Choice A rationale:

The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.

Choice B rationale:

The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.

Choice C rationale:

The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.

Choice D rationale:

The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.

Choice E rationale:

The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.

Choice F rationale:

The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.

Choice G rationale:

The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.