A nurse is planning care for a toddler who has measles. Which of the following isolation precautions should the nurse initiate?

Rationale

A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.

B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.

C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.

D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.

Rationale

A. Stroking the lower abdomen: Stroking the lower abdomen is not an evidence-based technique to stimulate bladder emptying. It may provide minimal sensory feedback but does not effectively trigger the micturition reflex in clients experiencing postoperative urinary retention.

B. Leaning backward when sitting and attempting to urinate: Leaning backward can actually impede proper bladder emptying by kinking the urethra. Proper positioning for urination involves sitting upright or leaning slightly forward to facilitate relaxation of the pelvic floor and urethral alignment.

C. Performing Kegel exercises prior to urination: Kegel exercises strengthen pelvic floor muscles and are useful for improving long-term urinary continence, but performing them immediately prior to attempting urination can tighten the muscles and hinder urine flow. This technique does not promote immediate bladder emptying.

D. Pouring warm water over the perineum: Pouring warm water over the perineum can stimulate sensory nerves and activate the micturition reflex, promoting bladder contraction and facilitating urination. This is a noninvasive, effective technique commonly used for clients experiencing postoperative urinary retention.