A nurse is planning care for a 4-year-old child who has leukemia and is receiving chemotherapy. The child has an absolute neutrophil count of 140/mm³. Which of the following interventions should the nurse include in the plan?

Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.

Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.

Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.

Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.

Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.

Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.

Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.

Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.