A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:

Encourage frequent physical activity to increase bone mass: While physical activity is generally beneficial for overall health, in the case of osteomyelitis, encouraging excessive or frequent physical activity might exacerbate pain, discomfort, and the risk of further bone injury. Controlled and appropriate physical activity may be recommended, but it should be individualized based on the child's condition and the affected area.

Choice B Reason:

Provide a high-calorie, low-protein diet: In osteomyelitis, a balanced and nutritious diet is important to support the child's overall health and aid in recovery. However, a high-calorie, low-protein diet would not be suitable for combating infection or supporting healing. Adequate protein intake is essential for tissue repair and immune function.

Choice C Reason:

Initiate contact precautions for the child: Osteomyelitis is not typically transmitted from person to person. It's an infection within the bone that doesn't require contact precautions for prevention of spread among individuals. Treatment primarily involves antibiotics and sometimes surgical drainage, but it doesn't necessitate isolation precautions.

Choice D Reason:

Maintain a patent intravenous catheter: Antibiotics are the mainstay of treatment for osteomyelitis, and they are usually administered intravenously for an extended period to effectively eradicate the infection. Maintaining a patent intravenous catheter ensures continuous access for medication administration.

Choice A Reason:

Assess respiratory status is correct. Ensuring the child's respiratory status is the first priority in any emergency situation. A head injury might result in an altered level of consciousness, which can compromise the child's ability to maintain a patent airway or adequate breathing. Assessing respiratory status involves observing breathing patterns, chest movements, and ensuring airway patency to ensure the child is adequately oxygenated.

Choice B Reason:

Examining the scalp for lacerations is incorrect. While assessing for any lacerations or external signs of head trauma is essential, it's not the primary immediate concern. The focus should be on ensuring the child's respiratory status and stabilizing their condition first.

Choice C Reason:

Checking pupil reactions is incorrect. Assessing pupil reactions is crucial in evaluating neurological function after a head injury. However, assessing respiratory status takes precedence as it is the most critical and immediate concern in any emergency situation.

Choice D Reason:

Inspecting for fluid leaking from the ears is incorrect. Fluid leaking from the ears might indicate a serious head injury, potentially involving the skull base. While this is an important assessment, it doesn't take priority over assessing the child's respiratory status, which is crucial for immediate intervention to ensure adequate oxygenation.