A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care?

Choice A Reason:

Allergy to neomycin is correct. Neomycin is an antibiotic, and individuals with a known severe allergic reaction to neomycin should avoid vaccines that contain this component. The MMR vaccine, along with some other vaccines, may contain trace amounts of neomycin, and individuals with a severe allergy to neomycin might be at risk for an allergic reaction if they receive a vaccine containing this substance.

Choice BReason:

Temperature of 37.2° C (99° F) is incorrect. A low-grade fever (slight elevation in temperature) is not a contraindication for the MMR vaccine unless the fever is part of a more severe illness or if the child has a high fever or is significantly unwell.

Choice CReason:

Family history of seizures is incorrect. A family history of seizures generally does not contraindicate the MMR vaccine. However, certain specific medical conditions or individual situations related to seizures might be considered by the healthcare provider.

Choice D Reason:

Upper respiratory infection 2 days ago is incorrect. Having had a mild upper respiratory infection in the recent past, especially if the child has recovered and is feeling well without any fever, is generally not a contraindication for the MMR vaccine. However, if the child is currently acutely ill or has a fever, the vaccine might be postponed until they are feeling better.

Choice A Reason:

Exhibits head lag when pulled to a sitting position is correct. At 5 months old, infants typically show improvement in head control, and head lag (where the infant's head falls back when pulled to a sitting position) should be diminishing. Persistent head lag might indicate potential developmental concerns or issues with muscle tone that warrant further evaluation by the healthcare provider.

Choice B Reason:

Unable to hold a bottle is incorrect. At 5 months old, some infants might not have developed the ability to hold a bottle independently yet. This skill can vary among infants and might not be a significant concern at this stage.

Choice C Reason:

Unable to roll from back to abdomen is incorrect. Rolling from back to abdomen might not be fully developed in all infants at 5 months old. It's a milestone that some infants achieve later within the 5 to 6-month range, so it might not be an immediate concern unless it persists significantly beyond that range.

Choice D Reason:

Absent grasp reflex is incorrect. By 5 months old, the typical infant's grasp reflex usually starts to diminish as voluntary grasping begins to develop. However, the absence of the grasp reflex might not be an immediate concern unless it's accompanied by other signs of developmental delay or regression.