A nurse is preparing a child who has suspected bacterial meningitis for a lumbar puncture. Which of the following cerebrospinal fluid findings supports the diagnosis?

Answer: B. Reposition the probe every 2 hours.

Rationale:

• A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
• B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
• C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
• D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

• The nurse should also choose a clean and dry site for probe placement.
• The probe should be snug but not too tight.
• The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
• If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

Choice A rationale:
This response indicates an understanding of the teaching about celiac disease. Rice is a gluten-free grain, which makes rice pudding a suitable dessert option for a child with celiac disease. Gluten is a protein found in wheat, barley, and rye, and individuals with celiac disease need to avoid gluten-containing foods.
Choice B rationale:
Barley is a gluten-containing grain, and feeding a child a barley-based breakfast cereal is not appropriate for someone with celiac disease. Gluten-containing grains can trigger adverse reactions in individuals with celiac disease due to their inability to properly digest gluten.
Choice C rationale:
Rye bread contains gluten, and making sandwiches using rye bread is not a suitable choice for a child with celiac disease. Gluten-free bread options, typically made from rice, corn, or other gluten-free flour, should be chosen instead.
Choice D rationale:
Chocolate malt may contain ingredients that could potentially contain gluten, and it's not a safe snack option for a child with celiac disease. Individuals with celiac disease need to be cautious about hidden sources of gluten in processed foods.