A nurse is caring for a child who is in a halo vest for cervical traction. Which of the following actions should the nurse take?

• Maintain infant in supine position: Given the infant's respiratory distress, including labored breathing, retractions, and nasal flaring, placing the infant in a supine position could worsen respiratory difficulties. The infant should be kept upright or in a semi-Fowler’s position to promote optimal breathing.
• Prepare the infant for a chest x-ray: A chest x-ray is crucial to assess the infant’s respiratory status and potential cardiac issues to identify any underlying causes of the symptoms, such as pneumonia, wheezing, cough, and labored breathing.
• Maintain infant on continuous pulse oximetry: Continuous pulse oximetry is essential for monitoring the infant's oxygen saturation levels. The infant is already on supplemental oxygen, and continuous monitoring will ensure that the oxygen levels are maintained and help identify any worsening of the respiratory condition.
• Monitor intake and output: Given the infant's poor feeding (consuming only half a bottle in the past 24 hours), monitoring intake and output is crucial to assess hydration status and nutritional needs. Decreased intake and output can indicate dehydration or worsening of the infant's condition.
• Initiate a peripheral IV line: Due to the infant’s poor feeding and the possibility of dehydration, establishing a peripheral IV line will allow for proper hydration and the administration of fluids or medications, as necessary, for the infant’s condition.
• Offer small, frequent feedings: Offering small, frequent feedings is appropriate for an infant with respiratory distress and decreased appetite. This can reduce the risk of aspiration and help ensure the infant receives adequate nutrition despite the difficulty with feeding.

Rationale for Correct Choices:

• Administer anticonvulsant: Since the adolescent is having symptoms that precede a seizure (blurred vision), administering an anticonvulsant as prescribed can help prevent or reduce seizure activity.
• Place the client lying on the side: Lying on the side ensures an open airway and reduces the risk of aspiration during a seizure. This position also allows secretions to drain safely.

Rationale for Incorrect Choices:

• Place a tongue blade in the client’s mouth: A tongue blade can cause injury to the teeth or mouth and increase choking risk. The proper approach is to place the client on their side and avoid putting objects in their mouth.
• Restrict movement in the extremities: Restricting movement could cause injury. The focus should be on safety by allowing the seizure to occur without interference while monitoring vital signs and activity.