The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.