A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

Choice A rationale:

The nurse should not include the instruction to "Avoid breastfeeding for 3 days after receiving the vaccine." This is not a necessary precaution for the MMR vaccine. Breastfeeding can continue after the MMR vaccination without any adverse effects on the infant.

Choice B rationale:

The correct instruction is to "Avoid pregnancy for at least 28 days after receiving the vaccine." This is because the MMR vaccine is a live attenuated vaccine, and there is a theoretical risk of transmitting the virus to a developing fetus. Waiting for 28 days after vaccination allows the woman's immune system to respond to the vaccine and reduce any potential risk to the fetus. This is especially important during the postpartum period when a woman may be at risk of becoming pregnant again.

Choice C rationale:

The statement "If you are allergic to gluten, you should not receive this vaccine" is not accurate. The MMR vaccine does not contain gluten as an ingredient. Allergic reactions to the MMR vaccine are generally related to components of the vaccine itself, not gluten.

Choice D rationale:

The instruction to "Your partner should also receive the MMR vaccine" is not a standard recommendation for postpartum women. While it is essential for individuals to be up-to-date on their vaccinations, the focus in this scenario should be on the postpartum woman receiving the MMR vaccine to protect herself and any future pregnancies.

Choice A rationale:

Using a firm-bristled toothbrush can increase the risk of gum injury or bleeding, especially in individuals with pernicious anemia who may have fragile gums due to vitamin B12 deficiency. This choice is correct because it identifies a risk factor for injury.

Choice B rationale:

Prescribing vitamin B12 intramuscularly (IM) is the appropriate treatment for pernicious anemia and does not increase the client's risk of injury. It is essential for addressing the underlying deficiency.

Choice C rationale:

Prescribing epoetin intravenously (IV) is used to stimulate the production of red blood cells and treat anemia, but it is not typically associated with an increased risk of injury. However, it should be administered as ordered by the healthcare provider.

Choice D rationale:

Sleeping 8 to 10 hours per night is beneficial for overall health and well-being. It does not increase the client's risk of injury. In fact, adequate sleep can help with tissue repair and overall recovery.