A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A) Two diarrhea stools in the last day: Diarrhea, especially if it is mild and without other severe symptoms, is not a contraindication for receiving a varicella vaccine. The child may still be able to receive the immunization if they are otherwise well. However, if the diarrhea is accompanied by fever, vomiting, or other signs of illness, the vaccine may be delayed.

B) Chemotherapy treatments: Chemotherapy treatments are a contraindication for the varicella vaccine. Chemotherapy can suppress the immune system, making the child more vulnerable to infections, including the risk of contracting varicella from the live vaccine. Immunocompromised patients should not receive live vaccines unless approved by their healthcare provider.

C) Clear rhinorrhea: Clear rhinorrhea, or a runny nose, typically indicates a mild upper respiratory condition like a cold. This is not a contraindication for receiving the varicella vaccine unless other symptoms are more severe or the child has a fever or signs of a more serious illness.

D) Medications for a cardiac anomaly: Medications for a cardiac anomaly do not generally interfere with the safety of the varicella vaccine. These medications may require careful monitoring for other reasons, but they are not contraindications to receiving the immunization, as long as the child is not immunocompromised from other causes

A) Mongolian spots: Mongolian spots are common in newborns of Asian, Hispanic, and African descent and are not specifically associated with fetal alcohol syndrome (FAS). These spots are bluish-gray or purple and typically fade over time, but they are not a manifestation of FAS.

B) Microcephaly: Microcephaly, which is an abnormally small head, is a common feature of fetal alcohol syndrome. This condition results from the effects of alcohol on the developing brain during pregnancy, leading to a smaller-than-normal head size.

C) Single palmar crease: A single palmar crease is a common finding in Down syndrome and can occur in other conditions as well, but it is not a hallmark feature of fetal alcohol syndrome. While it may occasionally be seen in infants with FAS, it is not one of the most common or defining characteristics.

D) Thin upper lip: A thin upper lip is one of the hallmark facial features of fetal alcohol syndrome. It is part of the characteristic "facial dysmorphology" seen in FAS, along with other features such as a smooth philtrum

E) Small eyes: Small eyes, or microphthalmia, are also a characteristic feature of fetal alcohol syndrome. This abnormal eye size, along with other facial abnormalities, is often seen in infants affected by FAS.