A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?

A. "Give her acetaminophen, not aspirin." This is the appropriate response. Acetaminophen is commonly recommended for treating fever in children as it is safer and does not carry the risk of Reye's syndrome, a rare but serious condition associated with aspirin use in children and adolescents, particularly when they have viral infections. This response provides a safe alternative and addresses the immediate concern of fever treatment.

B. "You'll have to call your physician." While consulting a physician is generally good advice, this response does not provide immediate guidance or address the potential risks of giving aspirin to a toddler. It leaves the parent without immediate and necessary information to prevent harm.

C. "Follow the directions on the aspirin bottle for her age and weight." This response is inappropriate and potentially harmful. Aspirin should not be given to children, especially without a physician's guidance, due to the risk of Reye's syndrome. Following dosage directions on an aspirin bottle is unsafe for a toddler, as aspirin is not recommended for children in this age group for fever treatment.

D. "Give her no more than three baby aspirin every 4 hours." This is incorrect and dangerous advice. Giving any amount of aspirin to a toddler is not recommended because of the risk of Reye's syndrome. Suggesting a specific dosage implies that it's safe to give aspirin to a child, which it is not in this context.

Place the infant in a knee-chest position: Indicated: ☑️

The knee-chest position is commonly used during a "tet spell," which involves episodes of cyanosis due to decreased oxygen levels. This position increases systemic vascular resistance, which helps redirect blood flow to the lungs, improving oxygenation.

Administer morphine via IV bolus: Indicated: ☑️

Morphine is used to calm the infant, reduce respiratory effort, and decrease pulmonary vascular resistance. It can help in reducing the severity of the tet spell by promoting better oxygenation.

Provide 100% oxygen by face mask: Indicated: ☑️

Administering 100% oxygen can help increase the amount of oxygen in the blood and reduce the effects of hypoxia. Oxygen is a vasodilator and can reduce pulmonary resistance, making it easier for the infant to oxygenate blood.

Request a prescription for a diuretic: Contraindicated: ☑️

Diuretics are generally not indicated in the acute management of tet spells. While they are used in conditions with fluid overload, their use in this context is not beneficial and could potentially worsen the infant's condition by causing dehydration and further reducing blood volume.

Perform nasopharyngeal suctioning for a maximum of 5 seconds: Contraindicated: ☑️

Nasopharyngeal suctioning can be stressful for the infant and may worsen cyanosis or provoke a tet spell due to increased agitation and respiratory effort. It's typically not recommended unless there's a clear indication for airway clearance.

Prepare to assist with the insertion of a chest tube: Contraindicated: ☑️

Chest tube insertion is not a treatment for tet spells or ToF. It is usually indicated for pneumothorax or significant pleural effusions, which are not related to the acute cyanotic episodes seen in ToF. Preparing for this procedure would be inappropriate in this scenario.