a nurse is planning to perform tracheostomy care for a toddler.
which of the following is an appropriate action for nurse to take?

The correct answer is Choice A.

Choice A rationale: Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.

Choice B rationale: Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.

Choice C rationale: Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.

Choice D rationale: Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.

Choice A rationale

An allergy to neomycin is a contraindication for receiving the measles, mumps, rubella (MMR) vaccine. Neomycin is an antibiotic that is used in some vaccines, including the MMR vaccine, to prevent bacterial contamination during the vaccine’s production. If a child has a known allergy to neomycin, they should not

receive the MMR vaccine because they could have a severe allergic reaction.

Choice B rationale

An upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine. While it’s generally recommended to wait until a child is healthy to give them a vaccine, a mild illness like a cold or upper respiratory infection usually isn’t a reason to delay vaccination.

Choice C rationale

A temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine. This temperature is within the normal range and does not indicate a fever or illness that would prevent vaccination.

Choice D rationale

A family history of seizures is not a contraindication for receiving the MMR vaccine. While febrile seizures can occur in some children after receiving the MMR vaccine, they are rare and are not more likely to occur in children with a family history of seizures.