The nurse is performing an assessment on a 2-year-old with otitis media. Which of the following actions would be appropriate? Select all that apply.

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11ecbb05_caf8_18bc_b433_efe6d96a08a2_MD0009_00 Acute otitis media is caused by a blocked eustachian tube, which leads to a buildup of purulent fluid and inflammation in the middle ear. Manifestations include a red and bulging tympanic membrane, inner ear pressure (which can rupture the tympanic membrane if not treated), pain, and fever (Option C). Clients also may have rhinorrhea, nausea, or vomiting. When assessing a toddler (age 1-3), the nurse should use the otoscope last because it often distresses clients in this age group, especially when pain is present (Option E). The nurse should insert the speculum only as far as the outer cartilaginous part of the external auditory canal. Advancing the speculum into the bony interior part causes pain and could damage the tympanic membrane (Option A). The nurse should educate the parents on how to avoid future occurrences of acute otitis media, which includes recommending influenza and pneumococcal conjugate vaccinations (Option B). (Option D) Children age <3 have a more horizontal external auditory canal than older children and adults. The nurse should pull the pinna down and back in infants and toddlers. Educational objective: When assessing a toddler's ear, the nurse should wait until the end of the assessment to use the otoscope, pull down and back on the pinna, insert the speculum no further than the outer external auditory canal, and inspect the tympanic membrane for signs of infection (eg, redness, bulging, perforation). The nurse should also recommend the influenza and pneumococcal conjugate vaccinations to prevent acute otitis media.

The Nurse Is Performing an Assessment on a 2-Year-Old with Otitis