A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions.

Initiate a protective environment.

Initiate contact precautions.

Initiate airborne precautions.

Answer and Explanation

The Correct Answer is A

A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.

B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.

C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.

D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.

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Correct Answer is C

Explanation

A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.

B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.

C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.

D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.

A. Attempt to obtain a throat culture. B. Use a tongue depressor to observe the back of the throat. C. Apply humidified oxygen via a mask. D. Initiate airborne precautions.

Correct Answer is C

Explanation

A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.

B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.

C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.

D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.

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A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?

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