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?

a.Log rolling is an appropriate technique to reposition a postoperative scoliosis repair patient as it minimizes stress on the spine and helps maintain spinal alignment. Patients need frequent repositioning to prevent pressure ulcers and promote comfort, but every 4 hours may not be frequent enough; typically, every 2 hours is recommended.

b.Protective isolation is not typically required for patients undergoing scoliosis surgery unless they have specific risk factors for infection (e.g., immunocompromised status). Standard postoperative care focuses on monitoring for infection at the surgical site rather than isolation unless indicated by the patient's condition.

c.While it’s important to elevate the head of the bed to assist with breathing and comfort, after scoliosis surgery, the head of the bed is generally elevated to 30-45° to facilitate lung expansion and reduce the risk of aspiration. However, it should be ensured that this angle does not compromise spinal alignment, especially in the early postoperative period.

d.The use of a patient-controlled analgesia (PCA) pump is an appropriate intervention for pain management after scoliosis surgery. It allows the patient to self-administer pain medication within prescribed limits, leading to more effective pain management, improved patient satisfaction, and potentially reduced need for supplemental analgesics.

a.Talcum powder is not recommended for use with infants because it can be inhaled, potentially causing respiratory problems. Instead, a barrier cream or ointment (such as zinc oxide or petroleum jelly) should be used to protect the skin from moisture and irritants.

b.While cloth diapers can be less irritating than some disposable diapers, they may not be as effective at keeping the skin dry. The priority is to keep the area dry and clean, regardless of the type of diaper used. Super-absorbent disposable diapers are often recommended because they can help keep the skin dry.

c.Exposing the skin to hot air can cause burns and further irritation. Instead, allowing the skin to air dry naturally (without the use of hot air) during diaper changes can be beneficial.

d.A moisturizer creates a barrier between the skin and irritants like urine and stool.Wiping with a moisturizer can minimize friction during cleaning, which can be uncomfortable for the baby and further irritate the skin.Some moisturizers can help soothe and hydrate the inflamed skin, promoting healing.