A nurse is performing an admission assessment of a school-age child who has spina bifida.
The parent states that the child is allergic to latex.
The nurse should assess further for cross-sensitivity to which of the following foods?

Administer high-dose antibiotic therapy.

Rationale:

• A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
• B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
• C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
• D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.

Choice B rationale:

Instructing the client to gently stroke her lower abdomen is the appropriate action in this situation. Gentle stroking or tapping on the lower abdomen can stimulate the bladder reflex and promote urination. This technique can help clients who have difficulty voiding, especially when using a bedpan. It encourages relaxation of the pelvic muscles, making it easier for the client to urinate.

Choice A rationale:

Turning on the faucets in the client's sink is not a recommended action for promoting urination. While the sound of running water can sometimes trigger the need to urinate, it may not be effective for every individual. Moreover, this action may not be practical or feasible in all healthcare settings.

Choice C rationale:

Instructing the client to lean slightly backward is not an appropriate action for promoting urination. Leaning backward can put pressure on the bladder, which may make it more challenging for the client to urinate. Encouraging relaxation and using techniques like gentle abdominal stroking are more effective in this situation.

Choice D rationale:

Pouring cool water over the client's perineum is not a recommended action for promoting urination. While some individuals find warm water soothing and relaxing, pouring cold water may cause discomfort and stress, making it even more difficult for the client to urinate. Gentle stimulation and relaxation techniques are generally more effective.