A nurse in a pediatric clinic is performing a history and physical for a toddler who is scheduled to receive a measles, mumps, and rubella (MMR) immunization. Which of the following findings indicate that the immunization should be withheld?

A. Increased respiratory rate: An increased respiratory rate may indicate that the child is experiencing respiratory distress or discomfort, which could be a sign that suctioning was not effective or that it was too aggressive. Ideally, after suctioning, the child's respiratory rate should stabilize or decrease as they are able to breathe more comfortably with a clear airway.

B. Decreased oxygen saturation: A decreased oxygen saturation level may indicate that the child is not receiving enough oxygen, which could be a sign of ineffective suctioning or airway obstruction. Effective suctioning should improve oxygenation by removing secretions and allowing for better airflow. A decrease in oxygen saturation would suggest the need for further assessment and intervention.

C. Clear breath sounds: This is the correct option. Clear breath sounds indicate that the airway has been effectively cleared of excess secretions, allowing for clear airflow. After suctioning, the nurse should listen for clear breath sounds without any crackles, wheezes, or other abnormal sounds indicating obstruction or congestion.

D. Increased oral secretions: Increased oral secretions may suggest that suctioning was not effective in clearing secretions from the airway, leading to pooling of secretions in the mouth. Effective suctioning should remove excess secretions from the airway, reducing the need for excessive oral secretions.

A. "Reye syndrome causes fatty changes in the liver."

This statement is correct. Reye syndrome is characterized by acute non-inflammatory encephalopathy and fatty changes in the liver, which can lead to liver dysfunction and failure.

B. "Reye syndrome leads to venous thrombus formation."

This statement is incorrect. Reye syndrome primarily affects the brain and liver, leading to cerebral edema and liver dysfunction. It does not typically involve venous thrombus formation.

C. "Reye syndrome is associated with misuse of acetaminophen."

This statement is incorrect. While the exact cause of Reye syndrome is not fully understood, it is not associated with the misuse of acetaminophen. However, there is a well-established association between Reye syndrome and the use of aspirin (salicylates) during viral infections, particularly in children and adolescents.

D. "Reye syndrome is linked to decreased serum ammonia levels."

This statement is incorrect. Reye syndrome is associated with increased serum ammonia levels due to liver dysfunction and impaired ammonia metabolism. Elevated ammonia levels can contribute to the encephalopathy seen in Reye syndrome.