A nurse is contributing to the plan of care for a toddler who is receiving intermittent enteral feedings. Which of the following interventions should the nurse include?

Rationale:

• Type of cough: The characteristic "barking" cough is typical of acute laryngotracheobronchitis (also known as croup), which affects the upper airways and results in a harsh, barking cough. Pneumonia causes a productive cough, which is not noted here. The non-productive cough in this case is more indicative of laryngotracheobronchitis.
• Fever: A low-grade fever is common in acute laryngotracheobronchitis and is consistent with this case (38.2°C to 38.9°C). Pneumonia can also cause fever, especially a higher-grade fever, but the fever.
• Stridor: Inspiratory stridor is a hallmark sign of acute laryngotracheobronchitis, caused by narrowing of the upper airway, leading to a high-pitched sound when breathing in. Stridor is not typically associated with pneumonia, as pneumonia primarily affects the lungs and causes symptoms like cough, difficulty breathing, and chest pain rather than airway narrowing.
• Irritability: Irritability is common in acute laryngotracheobronchitis due to discomfort from the cough, difficulty breathing, and fever. Irritability can also be seen in pneumonia, particularly in young children who may be uncomfortable due to fever, difficulty breathing, and general malaise.

A. “I’m guessing your other parent did not do anything to stop this from happening.”
This statement makes assumptions about the other parent's actions and could lead to further conflict or discomfort for the adolescent. It’s important to avoid making judgments and focus on providing support.
B. “Your parent was wrong to hit you for coming home late.” This statement may come across as judgmental or accusatory, which could hinder communication and trust with the adolescent. It's important to validate their feelings first and address the situation appropriately.
C. “It is not your fault that this happened to you.” This response is empathetic and supportive. It reassures the adolescent, which is an important step in helping them feel safe and understood. It also provides an opportunity for further discussion about their safety.
D. “I won’t tell anyone else about this unless you say it’s okay.” While privacy is important, this could be misleading. In cases of abuse, the nurse is required to report the situation to protect the adolescent, even if they don't consent.