A nurse is reviewing the medical records of a group of clients. Which of the following findings should the nurse report to local authorities?

Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.

Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.

Choice A rationale:
Edema. Edema, the accumulation of fluid in the tissues, is not the primary indicator of compartment syndrome. While edema can occur due to various reasons, it's not specific to compartment syndrome. Compartment syndrome primarily involves increased pressure within a closed space (muscle compartment), which can compromise blood circulation and nerve function.
Choice B rationale:
Mottling. Mottling refers to a patchy, bluish discoloration of the skin that occurs due to poor blood circulation and is often seen in critically ill patients. While it might indicate circulatory issues, it's not a direct sign of compartment syndrome. Compartment syndrome is more closely associated with symptoms such as severe pain, numbness, and decreased or absent pulses.
Choice C rationale:
Urticaria. Urticaria, also known as hives, is a skin rash characterized by raised, itchy, and red or white welts. It is typically caused by an allergic reaction or other factors such as medications. Urticaria is unrelated to compartment syndrome, which involves the compression of nerves and blood vessels within a closed anatomical compartment, leading to ischemia and potential tissue damage.
Choice D rationale:
Pulselessness. Pulselessness is a critical sign that the nurse should monitor when conducting a circulatory check for compartment syndrome. Compartment syndrome occurs when there is increased pressure within a confined space (muscle compartment), leading to compromised blood flow and oxygen delivery to the tissues. The lack of a palpable pulse in the affected area suggests that blood flow is severely compromised. This is a late sign of compartment syndrome and requires immediate intervention to prevent tissue necrosis and long-term complications.