A nurse is caring for a school-age child who had a tonic-clonic seizure 1 min ago. Which of the following actions should the nurse take?

Choice A rationale:
Hypertension is a common manifestation of acute glomerulonephritis. The inflammation of the glomeruli in the kidneys can lead to impaired filtration, causing fluid retention and an increase in blood pressure. Monitoring the child's blood pressure is crucial to assess the severity of the condition and guide appropriate interventions.
Choice B rationale:
Dehydration is not a typical manifestation of acute glomerulonephritis. In fact, this condition often leads to fluid retention due to impaired kidney function. The child might experience edema and hypertension rather than dehydration.
Choice C rationale:
Muehrcke lines on the nails are not associated with acute glomerulonephritis. Muehrcke lines are white lines that appear horizontally across the nails and are typically indicative of hypoalbuminemia, which is not a primary feature of glomerulonephritis.
Choice D rationale:
Hypokalemia, or low potassium levels, is not a characteristic manifestation of acute glomerulonephritis. This condition primarily affects the kidneys' ability to filter waste and excess fluid, leading to fluid retention, electrolyte imbalances, and hypertension.

Choice A rationale:
Correct Choice. Current pregnancy is a contraindication to administering the measles, mumps, and rubella (MMR) vaccine. The MMR vaccine contains live attenuated viruses, and it is generally contraindicated during pregnancy due to the potential risk to the developing fetus. Pregnant individuals should wait until after giving birth to receive the MMR vaccine.
Choice B rationale:
Mild ear infection is not a contraindication to administering the MMR vaccine. Mild illnesses, such as mild upper respiratory infections or low-grade fevers, are not typically considered contraindications for vaccination. In fact, immunization might be recommended in these cases to ensure protection against preventable diseases.
Choice C rationale:
A family history of seizures is not a contraindication to administering the MMR vaccine. Seizures are not known to be associated with the MMR vaccine. Therefore, a family history of seizures would not preclude an individual from receiving the vaccine.
Choice D rationale:
Severe peanut allergy is not a contraindication to administering the MMR vaccine. Allergies, including severe peanut allergies, are not considered contraindications for the MMR vaccine. Only individuals with a known severe anaphylactic allergy to a vaccine component (such as gelatin or neomycin) would have a contraindication to receiving the vaccine.