A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first?

A. Place the infant in prone position.

This option is incorrect. Placing the infant in the prone position (lying on the stomach) could put pressure on the spinal lesion, potentially causing discomfort or complications. It's important to minimize pressure on the affected area in infants with spina bifida.

B. Cover the infant's lesion with a dry cloth.

This option is incorrect. While keeping the lesion clean and dry is important for preventing infection, simply covering it with a dry cloth may not provide adequate protection. Proper wound care techniques, such as using sterile dressings and cleaning the area with prescribed solutions, are typically necessary to prevent infection and promote healing.

C. Feed the infant through an NG tube.

This option is incorrect. While infants with severe forms of spina bifida may have difficulty feeding due to associated complications, such as difficulty swallowing or weak sucking reflexes, feeding through a nasogastric (NG) tube is not a standard intervention for spina bifida itself. Feeding methods would depend on the specific needs and abilities of the infant, and may involve breastfeeding, bottle-feeding, or other methods under the guidance of healthcare professionals.

D. Diapering over a low defect will keep the infant free from infection.

This option is correct. Diapering over a low defect (the opening in the spine caused by spina bifida) helps to keep the area clean and reduce the risk of infection. By properly covering the defect with a diaper, exposure to urine and feces, which can increase the risk of infection, is minimized. Additionally, regular diaper changes and proper hygiene practices are essential for preventing complications in infants with spina bifida.

A. "Has your son had a sore throat recently?"

This question is relevant because acute rheumatic fever often occurs as a complication of untreated or inadequately treated streptococcal throat infection (strep throat). A recent history of sore throat could indicate a preceding streptococcal infection, which is an important predisposing factor for the development of acute rheumatic fever.

B. "Was your son born with this cardiac defect?"

This question is less relevant in the context of acute rheumatic fever. Acute rheumatic fever is not a congenital heart defect; it is an inflammatory condition that affects the heart valves following streptococcal infection. While it's important to assess the child's cardiac health, asking about congenital heart defects may not directly relate to the current condition.

C. "Are you aware that your son will have to be in isolation?"

This question is not applicable to acute rheumatic fever. Acute rheumatic fever is not a contagious condition that requires isolation. It is an autoimmune response triggered by streptococcal infection and does not pose a risk of transmission to others.

D. "Has your child had any injuries recently?"

Inquiring about recent injuries is not directly related to acute rheumatic fever. Acute rheumatic fever is an inflammatory condition primarily triggered by streptococcal infection and is not caused by physical injuries.