A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

A. The new onset of lethargy in a child with endocarditis is a significant concern, as it can indicate worsening infection or complications such as embolism. This child requires urgent assessment to prevent further deterioration.

B. Erythema of the lips in a child with Kawasaki disease is concerning, but this symptom is expected as part of the disease process. However, other signs like fever and conjunctivitis would be more concerning.

C. An increased erythrocyte sedimentation rate (ESR) in a child with rheumatic fever suggests inflammation, but it is not an immediate life-threatening concern like the lethargy in endocarditis.

D. Weak pedal pulses in a toddler with coarctation of the aorta indicate circulatory compromise, but this child may not be in immediate danger as the condition is often diagnosed and managed with interventions like surgery or medication.

A. Redness at the injection site is a common and mild reaction to vaccines. It does not typically require immediate medical intervention unless it worsens or is accompanied by more severe symptoms.

B. A temperature of 37.7° C (99.9° F) is a low-grade fever, which is a common, expected response after immunization. It is not a priority unless it increases significantly or is accompanied by other concerning symptoms.

C. Prolonged crying can sometimes occur after immunizations, but it is usually self-limited and resolves within a short period. If the crying is not excessive and does not indicate distress, it is generally not a priority concern.

D. Hives on the child’s neck could be a sign of an allergic reaction, such as anaphylaxis, which is a medical emergency. The nurse should immediately assess the child’s airway and provide necessary interventions, such as administering epinephrine, if required. This finding is the priority because it suggests a possible severe allergic response