A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to an adolescent. Which of the following should the nurse identify as a contraindication to administering this vaccine?

Answer: B. Reposition the probe every 2 hours.

Rationale:

• A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
• B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
• C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
• D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

• The nurse should also choose a clean and dry site for probe placement.
• The probe should be snug but not too tight.
• The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
• If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

Choice A rationale:
Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.
Choice B rationale:
Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.
Choice C rationale:
Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.
Choice D rationale:
Apply protective padding to the end of the pin sites. Rationale: This is the correct choice. Applying protective padding to the end of the pin sites is crucial to prevent pressure ulcers and infection. The pin sites are potential entry points for bacteria, and protecting them helps reduce the risk of infection. Padding also prevents pressure on the skin and underlying tissues, reducing the potential for pressure injuries.