A nurse in a pediatric clinic is performing a history and physical for a toddler who is scheduled to receive a measles, mumps, and rubella (MMR) immunization. Which of the following findings indicate that the immunization should be withheld?

Temperature of 38° C (100.4° F)

Family history of sudden unexpected infant death (SUID)

Taking an antihistamine for seasonal allergies

Receiving prednisone for nephrotic syndrome

Answer and Explanation

The Correct Answer is D

A. Temperature of 38°C (100.4°F): A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.

B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.

C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.

D. Receiving prednisone for nephrotic syndrome: Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR

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Correct Answer is C

Explanation

A. Steatorrhea: Steatorrhea refers to the presence of fat in the stool, which can indicate malabsorption or digestive issues, but it is not a typical symptom of a urinary tract infection (UTI). Therefore, it is not relevant to consider steatorrhea in the context of a UTI.

B. Jaundice: Jaundice is characterized by yellowing of the skin and eyes due to elevated levels of bilirubin in the blood. It is typically associated with liver or gallbladder problems and is not a common symptom of a UTI. Therefore, it is not relevant to consider jaundice in the context of a UTI.

C. Incontinence: Incontinence, or the inability to control urination, can be a symptom of a UTI in toddlers. UTIs can cause irritation of the bladder, leading to urgency, frequency, and in some cases, incontinence. Therefore, incontinence is a relevant finding to consider in the context of a UTI.

D. Rebound tenderness: Rebound tenderness is a sign of peritoneal irritation and is typically associated with conditions affecting the abdomen, such as appendicitis or peritonitis. It is not a typical symptom of a UTI. Therefore, it is not relevant to consider rebound tenderness in the context of a UTI.

A. Give the infant liquids using a small spoon with a long handle. B. Apply elbow restraints to the infant. C. Gently check the infant's suture line using a padded tongue depressor. D. Place the infant in a supine position.

Correct Answer is B

Explanation

A. Give the infant liquids using a small spoon with a long handle.

Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.

B. Apply elbow restraints to the infant.

Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.

C. Gently check the infant's suture line using a padded tongue depressor.

It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.

D. Place the infant in a supine position.

Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.

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A nurse in a pediatric clinic is performing a history and physical for a toddler who is scheduled to receive a measles, mumps, and rubella (MMR) immunization. Which of the following findings indicate that the immunization should be withheld?

Nursing Test Bank

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Correct Answer is C

Explanation

A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?

Correct Answer is B

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