A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

A) Places the infant in a side-lying position:

Positioning is important in the care of an infant with myelomeningocele. The infant is usually placed in a prone (on the abdomen) position to prevent pressure on the sac and protect the neural tissue. Placing the infant in a side-lying position may not provide the needed protection.

B) Maintains a dry dressing over the sac:

The sac should be kept moist with a sterile, non-adherent dressing moistened with saline to prevent drying and cracking, which could lead to infection.

C) Performs range of motion on the infant's hips:

Infants with myelomeningocele often have flaccid paralysis below the lesion, and excessive manipulation of the lower limbs could cause injury.

D) Takes an axillary temperature:

Rectal temperatures should never be taken, as they can cause mucosal damage or irritate the exposed spinal cord, leading to complications like meningitis. The axillary route is the safest method for temperature assessment.

A) Low-protein, low-potassium diet:

While low-protein and low-potassium diets can be appropriate for certain kidney conditions, such as chronic kidney disease, they are not typically the primary focus in the acute phase of glomerulonephritis. Protein restriction might be considered if there is significant kidney damage, and potassium levels are elevated.

B) Low-sodium fluid-restricted diet:

This is the most appropriate option. In acute glomerulonephritis, the kidneys' ability to regulate sodium and fluid balance may be impaired due to inflammation and decreased glomerular filtration. Fluid retention and peripheral edema are common. A low-sodium diet helps reduce fluid retention and manage edema.

C) Low carbohydrate, low-protein diet:

Low-carbohydrate and low-protein diets are not the main dietary considerations for acute glomerulonephritis. The primary focus is on managing sodium and fluid intake due to impaired kidney function.

D) Regular diet, no added salt:

A regular diet without added salt might exacerbate the fluid retention and edema associated with acute glomerulonephritis. Sodium intake needs to be controlled to prevent further fluid buildup.