A nurse on a pediatric intensive care unit is caring for a toddler who weighs 12 kg (26.5 lb) and is postoperative following open heart surgery. Which of the following findings should the nurse report to the provider?

Rationale:

A. Obtaining an x-ray of the child's neck may be necessary for diagnosis, but ensuring immediate safety and infection control measures take precedence.

B. Administering intravenous antibiotics is important in the treatment of epiglottitis but is not the immediate priority.

C. Initiating droplet precautions is crucial in this case to prevent the spread of infection to others but is not as important as securing the airway.

D. Placing intubation equipment at the bedside is the first priority because epiglottitis can cause airway obstruction and respiratory distress.

Rationale:

A. Nuchal rigidity when standing may indicate meningitis, but it is not a common complication of lumbar puncture itself.

B. Double vision is not a typical complication of lumbar puncture and suggests other neurological issues.

C. Headache is a common complication of lumbar puncture, occurring due to leakage of cerebrospinal fluid (CSF) from the puncture site. It is often described as positional, worsening when the patient sits or stands upright and improving when lying down.

D. Pain in the posterior iliac crest is not a typical complication of lumbar puncture and may indicate musculoskeletal issues unrelated to the procedure.