After administering varicella vaccine to a five-year-old child, which instruction should the nurse provide the child's parent?

Choice A reason: Weight gain of 0.5 kg/day is not a sign of a therapeutic response. It may indicate fluid retention, which is a common complication of nephrotic syndrome. Fluid retention occurs when the kidneys lose protein in the urine, leading to low blood protein levels and reduced oncotic pressure. This causes fluid to leak from the blood vessels into the tissues, resulting in edema and weight gain. The nurse should monitor the child's weight, fluid intake and output, and edema status.

Choice B reason: Decreased urinary output is not a sign of a therapeutic response. It may indicate kidney damage, which is a possible consequence of nephrotic syndrome. Kidney damage occurs when the glomeruli, the filtering units of the kidneys, become inflamed and scarred due to the loss of protein in the urine. This reduces the kidney's ability to filter waste and excess fluid from the blood, resulting in oliguria or anuria. The nurse should measure the child's urine specific gravity, creatinine, and blood urea nitrogen levels.

Choice C reason: Decreased periorbital edema is a sign of a therapeutic response. It indicates that the salt-poor human albumin IV is working to restore the blood protein levels and oncotic pressure. This helps to draw fluid back from the tissues into the blood vessels, reducing the swelling around the eyes and other parts of the body. The nurse should assess the child's skin turgor, capillary refill, and blood pressure.

Choice D reason: Increased periods of rest is not a sign of a therapeutic response. It may indicate fatigue, which is a common symptom of nephrotic syndrome. Fatigue occurs when the body loses protein and energy in the urine, leading to malnutrition and anemia. This causes the child to feel weak, tired, and lethargic. The nurse should provide the child with a high-protein, low-sodium diet, iron supplements, and adequate rest.

Choice A reason: Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.

Choice B reason: Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.

Choice C reason: Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.

Choice D reason: Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.