A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.

The child weighs 33 lb.

Which of the following actions should the nurse take?

The correct answer is choice D: Pediculosis capitis.

Choice D rationale: Pediculosis capitis is an infestation of head lice, which causes symptoms such as white flakes that do not brush off the hair easily and a rash on the back of the neck. These symptoms are due to the lice feeding on the scalp and laying eggs (nits), which can cause itching and irritation.

Choice A rationale: Folliculitis is an inflammation of the hair follicles, typically caused by bacterial or fungal infections. While it can cause a rash, it is not characterized by white flakes in the hair.

Choice B rationale: Tinea capitis, also known as ringworm of the scalp, is a fungal infection that causes scaly, itchy patches on the scalp. It may lead to hair loss in the affected areas, but it does not typically cause white flakes that do not brush off the hair.

Choice C rationale: Impetigo contagiosa is a highly contagious bacterial skin infection that causes blisters or sores on the skin. It does not involve white flakes in the hair and primarily affects exposed skin rather than the scalp.

A.Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.

B. Placing the infant in a side-lying positionis not recommended for a child with myelomeningocele. The preferred position isprone to avoid pressure on the sac and reduce the risk of rupture and infection.

C.Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.

D.Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.