A nurse is preparing to administer a vaccine to a toddler.
Which of the following actions should the nurse plan to take?

Choice A rationale

Collecting a stool culture is important for identifying the causative agent of diarrhea, such as bacteria, viruses, or parasites. This information is critical for determining the appropriate treatment and managing the child's symptoms effectively.

Choice B rationale

Offering apple juice or other sugary drinks can exacerbate diarrhea by drawing more fluid into the intestines and increasing stool frequency. Oral rehydration solutions are preferred.

Choice C rationale

Keeping the child NPO (nothing by mouth) for an extended period is not recommended, as it can lead to dehydration and does not address the underlying cause of diarrhea.

Choice D rationale

Weighing the child weekly is not sufficient for monitoring the immediate effects of diarrhea, such as dehydration and weight loss. More frequent assessments are necessary during acute episodes.

Choice C rationale

Hives on the child's neck is the priority finding because it can indicate an allergic reaction, which may progress to anaphylaxis. Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention. Hives are often the first sign of an allergic reaction and can quickly escalate to airway obstruction, difficulty breathing, and cardiovascular collapse. Early identification and treatment of an allergic reaction can prevent these severe complications. The nurse should be prepared to administer emergency medications, such as epinephrine, and provide respiratory support if needed.

Choice A rationale

Redness at the injection site is a common and expected local reaction following immunization. It typically resolves on its own without intervention. While it may cause some discomfort, it does not pose an immediate threat to the child's health and is not a priority over signs of a potential allergic reaction.

Choice B rationale

A temperature of 37.7°C (99.9°F) is a mild fever and a common response to immunizations as the body mounts an immune response. It is not usually cause for concern and can be managed with antipyretics if necessary. This mild fever does not indicate an urgent condition compared to the signs of an allergic reaction.

Choice D rationale

Prolonged crying can be a sign of discomfort or pain following an immunization but is not necessarily indicative of a severe reaction. It is important to assess the child's overall condition and provide comfort measures. However, it does not take precedence over signs of an allergic reaction, which require immediate attention.