A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

Initiate contact precautions.

Initiate standard precautions.

Initiate airborne precautions.

Initiate droplet precautions.

Answer and Explanation

The Correct Answer is D

Choice A: Contact precautions are not necessary for a child who has mumps, as mumps is not transmitted by direct or indirect contact with the infected person or their environment. Contact precautions are used for infections that are spread by contact with skin, wounds, body ﬂuids, or contaminated surfaces.

Choice B: Standard precautions are always used for any patient care, regardless of their diagnosis or infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe injection practices, and proper disposal of waste and sharps. However, standard precautions alone are not sufficient for a child who has mumps, as mumps are transmitted by respiratory droplets.

Choice C: Airborne precautions are not necessary for a child who has mumps, as mumps are not transmitted by small particles that remain suspended in the air and can be inhaled by others. Airborne precautions are used for infections that are spread by airborne transmission, such as tuberculosis, measles, or chickenpox.

Choice D: Droplet precautions are required for a child who has mumps, as mumps are transmitted by large respiratory droplets that are expelled when the infected person coughs, sneezes, or talks. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorts with other patients with the same infection, and limiting visitors and staﬀ who are susceptible to the infection.

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Correct Answer is D

Explanation

Choice A: The OUCHER scale is not suitable for a 2-month-old infant, as it is designed for children aged 3 to 13 years who can point to pictures of faces that match their pain level. A 2-month-old infant cannot communicate verbally or point to pictures.

Choice B: The FACES scale is not suitable for a 2-month-old infant, as it is designed for children aged 3 years and older who can select a face that matches their pain level. A 2-month-old infant cannot communicate verbally or select a face.

Choice C: The PAINAD scale is not suitable for a 2-month-old infant, as it is designed for adults who have advanced dementia and cannot verbalize their pain. A 2-month-old infant does not have dementia and may have diﬀerent behavioral indicators of pain.

Choice D: The FLACC scale is suitable for a 2-month-old infant, as it is designed for infants and children aged 2 months to 7 years who cannot verbalize their pain. The FLACC scale assesses five behavioral indicators of pain: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2 based on the observation of the nurse. The total score ranges from 0 to 10, with higher scores indicating more pain.

A. Distended neck veins B. Rigid abdomen C. Projectile vomiting D. Red currant jelly stools

Correct Answer is C

Explanation

Choice A: Distended neck veins are not a clinical manifestation of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Distended neck veins are a sign of increased venous pressure, which can occur in conditions that affect the right side of the heart or cause ﬂuid overload.

Choice B: Rigid abdomen is not a clinical manifestation of pyloric stenosis, but rather a sign of peritonitis, which is inﬂammation of the peritoneum, which is the membrane that lines the abdominal cavity. Peritonitis can be caused by infection, perforation, or trauma to any abdominal organ. A rigid abdomen indicates severe pain and inﬂammation in the abdominal cavity.

Choice C: Projectile vomiting is a clinical manifestation of pyloric stenosis, as it indicates forceful expulsion of stomach contents due to obstruction at the pylorus. Projectile vomiting can occur shortly after feeding and may contain undigested milk or formula. Projectile vomiting can cause dehydration, electrolyte imbalance, or weight loss.

Choice D: Red currant jelly stools are not a clinical manifestation of pyloric stenosis, but rather a sign of intussusception, which is a condition that causes telescoping of one segment of bowel into another. Intussusception can cause obstruction and ischemia of the bowel and lead to bleeding and necrosis. Red currant jelly stools indicate blood and mucus in the stool.

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A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?

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