A nurse is assisting with the plan of care for10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

D. Facial nerve assessment: The development of left facial droop and asymmetry postoperatively suggests potential facial nerve (cranial nerve VII) injury during the stapedectomy. This requires immediate evaluation to determine if it is temporary due to surgical manipulation or a sign of nerve damage.
E. Vertigo: Postoperative vertigo and nausea are common but should be monitored closely because stapedectomy involves inner ear structures responsible for balance. Persistent or worsening vertigo may indicate inner ear trauma or perilymphatic fistula, requiring further assessment.

Incorrect:
A. Pain rating: Pain is expected after surgery and can be managed with prescribed analgesics.
B. Lung assessment: Bilateral clear breath sounds do not indicate respiratory distress or complications.
C. Pupils: The slight decrease in pupil size (3.5 mm to 3 mm) is not clinically significant and remains within normal limits.
F. Diminished hearing: Hearing loss is expected post-stapedectomy due to packing in the ear and middle ear healing. Improvement typically occurs over weeks.

A) Administer granulocyte colony stimulating factor: Granulocyte colony-stimulating factor (G-CSF) is used to stimulate white blood cell production in certain conditions like neutropenia. However, in an infant with HIV, the primary concern is the HIV progression and monitoring for complications rather than administering G-CSF. It is not routinely used for infants with HIV unless there is a specific indication such as neutropenia.

B) Monitor the infant's lymphocyte count: Monitoring the infant’s lymphocyte count is an appropriate and essential intervention. HIV affects the immune system by targeting CD4+ T lymphocytes, so tracking the lymphocyte count will help gauge the progression of the disease and the effectiveness of the treatment. It is vital to assess the infant’s immune status, as HIV can lead to a weakened immune system and increase susceptibility to infections.

C) Initiate droplet precautions: Droplet precautions are typically required for infections like influenza or certain respiratory illnesses. HIV is not transmitted via droplets; it is primarily transmitted through blood, sexual contact, and from mother to child during childbirth or breastfeeding. Therefore, droplet precautions are not necessary for this infant.

D) Educate the infant's guardians about exchange transfusions: Exchange transfusions are generally not a routine intervention for infants with HIV unless there is a specific complication like severe hyperbilirubinemia or other hematologic conditions. The focus for infants with HIV is on managing antiretroviral therapy (ART) and preventing infections, rather than performing exchange transfusions. Educating the guardians about ART and infection prevention would be more appropriate.