A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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) Place a tongue depressor in the client's mouth:

Incorrect. Placing a tongue depressor in the client's mouth is not recommended during a seizure. Doing so can lead to injury, as the child may bite down on the depressor and cause harm to their teeth or mouth.

B) Restrain the client:

Incorrect. Restraining a person during a seizure can be extremely dangerous. It can lead to physical harm to both the person experiencing the seizure and the person trying to restrain them. Restraining can increase the risk of fractures, dislocations, and other injuries.

C) Assess the client's airway patency:

Correct. Assessing the client's airway patency is essential during a seizure. The nurse should ensure that the child's airway is clear and open to maintain proper breathing. This involves observing for any obstruction or difficulty in breathing and taking appropriate measures to keep the airway open.

D) Remove objects from the client's bed:

Correct. Removing objects from the client's bed is a necessary action to prevent injury during a seizure. Objects on the bed can pose a risk of harm to the child if they were to strike them during the seizure. Creating a safe environment by removing potential hazards is important.

E) Place the client in a side-lying position:

Correct. Placing the client in a side-lying position is recommended during a seizure. This position helps prevent aspiration and maintains a clear airway. It also reduces the risk of choking and allows any fluids to drain from the mouth, minimizing the risk of choking.

In summary:

Choice A is incorrect because placing a tongue depressor can cause injury.

Choice B is incorrect because restraining can lead to harm.

Choice C is correct because assessing the airway ensures proper breathing.

Choice D is correct because removing objects reduces the risk of injury.

Choice E is correct because placing the client in a side-lying position helps maintain a clear airway and prevents aspiration.