A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?
"My child has some swelling around her eyelids and mouth."
"My child has a temperature of 100.7 degrees Fahrenheit."
"My child only ate 2 ounces during her last feeding."
"My child cries when I touch the area where she received the shot.".
The Correct Answer is A
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
No explanation
Correct Answer is A
Explanation
Choice A rationale:
A positive leukocyte esterase test indicates the presence of white blood cells (leukocytes) in the urine, which can be an indicator of a urinary tract infection (UTI). White blood cells are part of the body's immune response and their presence in the urine suggests inflammation and infection in the urinary tract.
Choice B rationale:
Deep gold-colored urine is not typically associated with a urinary tract infection. Normally, urine color can vary based on hydration, diet, and other factors, but color alone is not a reliable indicator of a UTI.
Choice C rationale:
The osmolality of 700 mOsm/L is not a specific finding related to urinary tract infections. Osmolality measures the concentration of particles in the urine and can vary based on hydration status. While it might be elevated in a concentrated urine sample, it is not a direct indicator of a UTI.
Choice D rationale:
A specific gravity of 1.015 is within the normal range and does not necessarily indicate a urinary tract infection. Specific gravity measures the concentration of solutes in the urine and can be influenced by hydration levels and kidney function. A UTI would primarily be indicated by the presence of white blood cells and other signs of infection in the urine.
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