A nurse is assessing an infant who has acute otitis media.
Which of the following findings should the nurse expect? (Select all that apply.)

Fever.

Crying.

Enlarged subclavicular lymph node.

Restlessness.

Increased appetite.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Fever is a common sign of acute otitis media, indicating an infection. Elevated body temperature is a natural response to infection as the body tries to fight off the invading pathogens.

Choice B rationale:

Crying is a common symptom in infants with acute otitis media due to ear pain and discomfort caused by the infection. It is a way for the infant to express distress.

Choice C rationale:

Enlarged subclavicular lymph node is not a typical finding in acute otitis media. Enlarged lymph nodes can indicate an immune response but are not specific to this condition.

Choice D rationale:

Restlessness can be a symptom of acute otitis media. Infants may become irritable and have difficulty sleeping due to ear pain and discomfort.

Choice E rationale:

Increased appetite is not a typical finding in acute otitis media. Illnesses often cause a decreased appetite rather than an increased one.

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Correct Answer is D

Explanation

Choice Arationale:

A temperature of 37.2°C (99°F) is slightly elevated but not a contraindication for the MMR vaccine. Low-grade fever is a common side effect of vaccines and is not a reason to withhold vaccination. The nurse should advise the parents to consult with the healthcare provider if the child has a moderate to high fever.

Choice Brationale:

Family history of seizures is not a contraindication for the MMR vaccine. The MMR vaccine is safe for individuals with a family history of seizures. However, if the child has a personal history of seizures, especially related to fever (febrile seizures), the healthcare provider should be consulted before vaccination.

Choice C rationale:

An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. Minor illnesses without fever or systemic symptoms are not reasons to postpone routine vaccinations. The child should receive the vaccine as scheduled.

Choice D rationale:

Allergy to neomycin is the correct choice. Neomycin is an antibiotic that is sometimes present in vaccines, including the MMR vaccine. Individuals with a known allergy to neomycin should not receive vaccines containing this substance due to the risk of an allergic reaction. It is essential to screen for allergies to vaccine components to ensure the child's safety during vaccination.

A. Feed the infant 177.4 mL (6 oz) of formula three times each day. B. Elevate the infant's head to a 10° angle during feedings. C. Discontinue a feeding if the infant's eyes become watery. D. Postpone burping the infant until after completing each feeding.

Correct Answer is B

Explanation

Choice A rationale:

Feeding the infant a specific volume of formula is not the priority when caring for a child with a cleft of the soft palate. Infants with cleft palate may have difficulty creating suction during feeding, which can lead to inefficient feeding and inadequate intake. It is essential to focus on proper feeding techniques rather than a specific volume.

Choice B rationale:

Elevating the infant's head to a 10° angle during feedings is the correct action. This positioning helps prevent formula or breast milk from flowing into the nasal cavity, reducing the risk of aspiration. Aspiration can lead to respiratory issues and other complications. Elevating the head facilitates swallowing and reduces the risk of choking.

Choice C rationale:

Discontinuing a feeding if the infant's eyes become watery is not a valid indication to stop feeding. Watery eyes are not directly related to feeding difficulties in infants with a cleft palate. It is essential to assess the infant's overall feeding performance and address specific issues such as inadequate suction or swallowing difficulties.

Choice D rationale:

Postponing burping until after completing each feeding is not appropriate. Burping should be done periodically during feedings to prevent the accumulation of air in the infant's stomach, which can cause discomfort and contribute to reflux. Burping helps release trapped air and promotes comfortable feeding experiences for the infant.

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A nurse is assessing an infant who has acute otitis media.Which of the following findings should the nurse expect? (Select all that apply.)

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A nurse is assessing an infant who has acute otitis media.
Which of the following findings should the nurse expect? (Select all that apply.)