A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

Choice A: Performing range of motion on the infant's hips is not appropriate for an infant who has myelomeningocele, which is a type of spina bifida that causes a sac-like protrusion of the spinal cord and nerves through an opening in the spine. Performing range of motion on the infant's hips can cause nerve damage or pain in the lower extremities, which may already be affected by the condition.

Choice B: Taking an axillary temperature is appropriate for an infant who has myelomeningocele, as it is a non-invasive and accurate method of measuring body temperature. An axillary temperature is taken by placing a thermometer under the armpit and holding the arm close to the body. Taking an axillary temperature can help monitor for signs of infection or inflammation, which are common complications of myelomeningocele.

Choice C: Placing the infant in a side-lying position is not appropriate for an infant who has myelomeningocele, as it can cause pressure or friction on the sac and increase the risk of rupture or infection. The correct position for an infant with myelomeningocele is prone with hips slightly flexed and legs abducted. This position can prevent trauma and promote drainage from the sac.

Choice D: Maintaining a dry dressing over the sac is not appropriate for an infant who has myelomeningocele, as it can cause irritation or infection of the sac and surrounding skin. The correct dressing for an infant with myelomeningocele is moist and sterile with saline or antibiotic solution. This dressing can prevent drying and cracking of the sac and reduce bacterial growth.

Choice A reason: This choice is incorrect because a 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F) is not the most urgent case to assess. Roseola is a viral infection that causes a rash on the trunk and limbs, followed by a high fever that lasts for several days. It usually affects infants and young children and is self-limiting.
The fever can be managed by giving antipyretics such as acetaminophen or ibuprofen, and by providing fluids and comfort measures. The fever does not indicate any serious complication or threat to life.

Choice B reason: This choice is incorrect because a 4-year-old child who has asthma and an O2 sat of 97% is not the most urgent case to assess. Asthma is a chronic respiratory condition that causes inflammation and narrowing of the airways, leading to wheezing, coughing, chest tightness, or shortness of breath. It may be triggered by allergens, irritants, exercise, or infections. The O2 sat is a measure of oxygen saturation in the blood, which indicates how well oxygen is delivered to the tissues. A normal O2 sat range is 95% to 100%, so an O2 sat of 97% indicates that the child has adequate oxygenation and is not in respiratory distress.

Choice C reason: This choice is correct because a 10-year-old child who has sickle cell anemia and reports severe chest pain is the most urgent case to assess. Sickle cell anemia is a genetic disorder that causes the red blood cells to become sickle-shaped and clump together, blocking the blood flow and oxygen delivery to the organs and tissues. It may cause severe pain in the chest, abdomen, joints, or bones, as well as symptoms such as pallor, jaundice, fatigue, or shortness of breath. Severe chest pain may indicate acute chest syndrome, which is a life-threatening complication of sickle cell anemia that involves infection or infarction of the lungs. It may cause fever, cough, hypoxia, or respiratory failure. Therefore, assessing and treating this child is a priority to prevent further damage and death.

Choice D reason: This choice is incorrect because a 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 is not the most urgent case to assess. Diabetes insipidus is a rare disorder that affects the balance of fluids in the body. It causes the kidneys to produce large amounts of dilute urine, leading to polyuria, polydipsia, dehydration, or electrolyte imbalance. It may be caused by a deficiency of antidiuretic hormone (ADH) or a resistance to its action. The urine specific gravity is a measure of urine concentration, which indicates how well the kidneys are functioning. A normal urine specific gravity range is 1.005 to 1.030, so a urine specific gravity of 1.016 indicates that the child has normal urine concentration and is not dehydrated.