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

The correct answer is choice b. Stretch the perineum taut when applying the bag.

Choice A rationale:

Positioning the opening of the bag over both the urethra and the anus is incorrect because it increases the risk of contamination from fecal matter, which can lead to inaccurate test results.

Choice B rationale:

Stretching the perineum taut when applying the bag ensures a secure fit and reduces the risk of leakage, which is essential for accurate urine collection.

Choice C rationale:

Applying lidocaine gel to the perineum before attaching the bag is not recommended as it is unnecessary and could cause irritation or an allergic reaction in the infant.

Choice D rationale:

Placing a snug-fitting diaper over the drainage bag is not the correct action because it can cause the bag to become dislodged or compressed, leading to inaccurate collection or spillage.

Choice A rationale:

Weighing the child once each month is not the most relevant information to include in teaching parents of a preschool-age child with heart failure. Monitoring weight is important, but it should be done more frequently, preferably daily, to track any sudden weight gain, which could indicate fluid retention and worsening heart failure.

Choice B rationale:

Withholding digoxin if the child's pulse is greater than 100/min is not appropriate. Digoxin is commonly prescribed for heart failure in pediatric patients to strengthen the heartbeat. Instead, the nurse should teach the parents to monitor the child's pulse rate regularly and report any significant changes to the healthcare provider.

Choice C rationale:

Increasing the child's oxygen flow rate until the child no longer has cyanosis is incorrect. While oxygen therapy might be necessary for a child with heart failure, adjusting the oxygen flow rate based on cyanosis is not the appropriate approach. Oxygen therapy should be prescribed and monitored by healthcare providers based on the child's oxygen saturation levels.

Choice D rationale:

Providing for periods of rest is the correct choice. Children with heart failure often tire easily due to the heart's reduced ability to pump blood effectively. Allowing the child to rest helps conserve energy and prevents additional strain on the heart. This instruction promotes the overall well-being and comfort of the child, aligning with the management of heart failure.