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 reason: This choice is incorrect because constructing a model airplane is not an appropriate activity for a 4- year-old child who requires airborne precautions. Airborne precautions are infection control measures that prevent the transmission of microorganisms that can be spread by small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. They involve placing the child in a negative-pressure room with a HEPA filter, wearing a respirator mask, and limiting movement outside the room. Constructing a model airplane may involve small parts that can be choking hazards, sharp edges that can cause injury or glue that can cause irritation or allergy. Therefore, this activity may not be safe or suitable for the child.

Choice B reason: This choice is incorrect because pulling a wagon with toys in the hallway is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Pulling a wagon with toys in the hallway may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be allowed or advisable for the child.

Choice C reason: This choice is correct because putting a large-piece puzzle together is an appropriate activity for a 4-year-old child who requires airborne precautions. Putting a large-piece puzzle together can help to stimulate the child's cognitive, visual, and fine motor skills by requiring them to match shapes, colors, and patterns. It can also help to reduce boredom, frustration, or anxiety by providing entertainment, diversion, or achievement. Therefore, this activity may be beneficial and enjoyable for the child.

Choice D reason: This choice is incorrect because watching a video game in the playroom is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Watching a video game in the playroom may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be permitted or recommended for the child.

Choice A:In actual practice, log rolling is typically done every 2 hoursto align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT).
as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff
members to assist with log rolling.

Choice B: This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.

Choice C: This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. The nurse should follow standard precautions and surgical site care to prevent infection in this client.

Choice D: This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.