A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.)

Choice A reason: Gingival hyperplasia is a condition where the gums become enlarged and inflamed. It is a common side effect of Phenytoin, a medication used to treat seizures. The nurse should educate the client and the guardian about the importance of oral hygiene and regular dental check-ups to prevent or manage this condition.

Choice B reason: Hypoglycemia is a condition where the blood glucose level becomes too low. It is not a common side effect of albuterol, a medication used to treat asthma. Albuterol may cause tremors, tachycardia, or nervousness, but not hypoglycemia.

Choice C reason: Status epilepticus is a condition where seizures occur repeatedly without recovery. It is a medical emergency that requires immediate treatment. It may be triggered by exercise, but not necessarily. The nurse should ensure that the client has their seizure medication and rescue inhaler available at all times and knows how to use them.

Choice D reason: Bronchospasm is a condition where the airways become narrowed and obstructed. It is a common symptom of asthma, but not a side effect of Phenytoin. Phenytoin may cause other adverse effects, such as rash, nausea, or drowsiness, but not bronchospasm.

Choice A reason: Bacterial meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord, caused by a bacterial infection. It can cause fever, headache, neck stiffness, photophobia, and altered mental status. The cerebrospinal fluid (CSF) analysis may show increased white blood cells, protein, and glucose. The nurse should assess the neck range of motion and the reaction to pupil assessment, as these may indicate increased intracranial pressure.

Choice B reason: Encephalitis is an inflammation of the brain tissue, usually caused by a viral infection. It can cause fever, headache, confusion, seizures, and focal neurological deficits. The CSF analysis may show increased white blood cells and protein, but normal glucose. The nurse should assess the level of consciousness and the neurological status, as these may indicate brain damage.

Choice C reason: Gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. It can cause nausea, vomiting, diarrhea, abdominal pain, and dehydration. The nurse should assess the gastrointestinal manifestations and the vital signs, as these may indicate fluid and electrolyte imbalance.

Choice D reason: Migraine is a type of headache that involves recurrent episodes of moderate to severe pain, usually on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The nurse should assess the location and duration of pain, the triggers and relievers, and the history of migraine. The CSF analysis is usually normal.