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

The correct answer is Choice D.

Choice A rationale

A positive Babinski reflex is normal in infants up to 2 years old and indicates normal neurological development.

Choice B rationale

A negative Doll’s eye reflex is concerning as it may indicate a neurological problem. However, it is not as critical as a positive Moro reflex in a 9-month-old.

Choice C rationale

A negative Crawl reflex may indicate developmental delays, but it is not as critical as a positive Moro reflex in a 9-month-old.

Choice D rationale

A positive Moro reflex is abnormal in a 9-month-old and may indicate neurological issues. This reflex typically disappears by 2 months of age. .

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.