A nurse is caring for an adolescent who has been diagnosed with diabetic ketoacidosis (DKA). The nurse notes the following:

Exhibits

When planning care for this client, the nurse should anticipate a provider's prescription for which of the following?

Choice A reason: Maintaining the infant in the supine position is not an appropriate intervention, as it can increase the pressure on the myelomeningocele sac and cause further damage to the spinal cord. The nurse should position the infant prone or side-lying, with the head turned to one side and the hips flexed.

Choice B reason: Limiting visitors to immediate family members is not a necessary intervention, as the infant does not have an infectious condition that requires isolation. The nurse should encourage the parents and other family members to visit and bond with the infant, and provide emotional support and education.

Choice C reason: Initiating contact precautions is not a required intervention, as the infant does not have a contagious condition that poses a risk of transmission to others. The nurse should follow standard precautions, such as washing hands, wearing gloves, and disposing of contaminated materials properly.

Choice D reason: Providing a latex-free environment is an essential intervention, as the infant has a high risk of developing a latex allergy due to the frequent exposure to latex products during surgery and other procedures. The nurse should avoid using latex gloves, catheters, syringes, bandages, or other items that contain latex, and use alternative materials instead. The nurse should also label the infant's chart, crib, and door with a latex allergy alert.

Choice A reason: Acetaminophen suppository is not a likely prescription, as it is used to reduce fever and pain, which are not the main problems of the toddler. The toddler has a high axillary temperature of 39.5°C (103.1°F), which is not considered a fever in children under 2 years old. The normal axillary temperature range for children is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B reason: Oral rehydration solution is not a probable prescription, as it is used to prevent or treat dehydration caused by diarrhea, vomiting, or excessive sweating, which are not the main problems of the toddler. The toddler has a normal respiratory rate of 22/min and oxygen saturation of 98%, which indicate adequate hydration and oxygenation.

Choice C reason: Nebulized albuterol is a possible prescription, as it is used to treat bronchospasm, which is a common complication of respiratory infections in children. The toddler has a high apical heart rate of 142/min, which may indicate respiratory distress or hypoxia. The toddler is also pulling at his ear, which may indicate an ear infection or pain.

Choice D reason: Intravenous antibiotics are not a likely prescription, as they are used to treat bacterial infections, which are not the main problems of the toddler. The toddler has no signs or symptoms of a bacterial infection, such as purulent discharge, foul odor, or localized inflammation. The toddler may have a viral infection, which does not respond to antibiotics.