A nurse is collecting data from an infant who has otitis media.
Which of the following findings should the nurse identify as manifestations of pain in an infant? (Select all that apply)

Choice A rationale

Lethargy in a child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt could indicate a serious problem such as shunt malfunction or infection, and should be the priority.

Choice B rationale

A respiratory rate of 20/min is within the normal range for a 4-year-old child and is not typically a cause for concern.

Choice C rationale

Lying flat on the unaffected side is not typically a cause for concern following ventriculoperitoneal shunt surgery.

Choice D rationale

A urine output of 50 mL in 2 hr is within the normal range for a 4-year-old child and is not typically a cause for concern.

Choice A rationale

Children with spina bifida often are allergic to latex, which can be found in medical gloves and things such as bandages, balloons, and pacifiers. Therefore, latex precautions should be taken while caring for a child with spina bifida.

Choice B rationale

Neutropenic precautions are typically used for patients with a low white blood cell count (neutropenia), which makes them more susceptible to infections. There is no specific association between spina bifida and neutropenia, so these precautions would not typically be necessary unless the child has a co-existing condition that causes neutropenia.

Choice C rationale

Seizure precautions are typically used for patients with a seizure disorder, such as epilepsy. While some individuals with spina bifida may also have a seizure disorder, it is not a common feature of the condition. Therefore, seizure precautions would not typically be necessary unless the child has a co-existing seizure disorder.

Choice D rationale

Contact precautions are typically used for patients who have an infection that can be spread by direct contact. There is no specific association between spina bifida and infectious diseases that would require contact precautions, so these precautions would not typically be necessary unless the child has a co-existing infectious disease.