A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?

A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.

B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.

C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.

D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.

A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.

B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.

C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.

D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.

A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.

B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.

C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.

D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.

Increased seizure activity

• Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

• Finding: Cough

A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

• Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

• Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

• Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.