A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.

Choice B rationale

Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.

Choice C rationale

Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.

Choice D rationale

Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.

Choice A rationale

An allergy to neomycin is a contraindication for receiving the measles, mumps, rubella (MMR) vaccine. Neomycin is an antibiotic that is used in some vaccines, including the MMR vaccine, to prevent bacterial contamination during the vaccine’s production. If a child has a known allergy to neomycin, they should not

receive the MMR vaccine because they could have a severe allergic reaction.

Choice B rationale

An upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine. While it’s generally recommended to wait until a child is healthy to give them a vaccine, a mild illness like a cold or upper respiratory infection usually isn’t a reason to delay vaccination.

Choice C rationale

A temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine. This temperature is within the normal range and does not indicate a fever or illness that would prevent vaccination.

Choice D rationale

A family history of seizures is not a contraindication for receiving the MMR vaccine. While febrile seizures can occur in some children after receiving the MMR vaccine, they are rare and are not more likely to occur in children with a family history of seizures.