A nurse is assisting with the care of several clients. The nurse should identify that which of the following client conditions requires contact precautions?

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

A.This is the best action for the nurse to take. Continuous monitoring increases the risk of skin breakdown and pressure necrosis at the sensor site. Rotating the probe site every 2 to 4 hours ensures that the underlying tissue receives adequate circulation and prevents thermal or mechanical injury to the skin.

B. Taping the wire to the palm of the hand is not recommended because it may cause skin irritation or pressure injury. The sensor should be placed on a finger or toe, where blood flow is easily accessible.

C. Applying the sensor to the index fingernail is not ideal. Pulse oximetry is most accurate when applied to a finger or toe, but not directly on the nail itself. It should be placed on the skin near the nail.

D. While adequate perfusion is necessary for an accurate reading, warming the skin is not a routine requirement for probe placement. If a child has poor peripheral circulation (cold extremities), a different site with better perfusion, such as the earlobe or forehead, should be chosen rather than attempting to warm the skin, which could lead to accidental burns if a heat source is used improperly.