A nurse is caring for a 2-month-old child. The child’s provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?

Choice A reason: Isotonic dehydration involves equal loss of water and electrolytes, reducing circulating volume. This can lead to hypovolemic shock, characterized by hypotension and organ hypoperfusion, risking multi-organ failure. In children, rapid fluid loss from diarrhea or vomiting makes this the greatest life-threatening complication, requiring urgent fluid resuscitation.

Choice B reason: Metabolic acidosis may occur in dehydration from bicarbonate loss (e.g., diarrhea), but it is less immediately life-threatening than hypovolemic shock. Acidosis causes compensatory tachypnea but rarely leads to rapid death. Shock’s impact on perfusion is the primary threat, making acidosis a secondary concern in isotonic dehydration.

Choice C reason: Hypernatremia occurs in hypertonic dehydration, not isotonic, where sodium levels remain normal. Isotonic dehydration’s primary risk is volume depletion, leading to hypovolemic shock. Hypernatremia causes neurological symptoms but is not the main threat, as isotonic dehydration maintains electrolyte balance, making this incorrect.

Choice D reason: Seizures may occur in dehydration from electrolyte imbalances like hyponatremia, but isotonic dehydration maintains normal sodium levels, reducing seizure risk. Hypovolemic shock, from significant volume loss, is the greatest threat, causing cardiovascular collapse, making seizures a less immediate concern in this scenario.

Choice A reason: NPH insulin has an onset of 1-2 hours, peaking at 4-12 hours. At 0900, 2 hours post-administration, the effect is minimal, with low hypoglycemia risk. Peak action, when hypoglycemia is most likely due to maximum glucose-lowering effect, occurs later, making this time less critical for monitoring.

Choice B reason: At 0730, only 30 minutes post-NPH insulin, the medication’s onset has not occurred, as it takes 1-2 hours to begin lowering glucose. Hypoglycemia is unlikely this early, as insulin levels are not yet significant. Peak effect at 4-12 hours is when monitoring is critical, making 0730 incorrect.

Choice C reason: NPH insulin peaks at 4-12 hours, with significant glucose-lowering effects by 1100 (4 hours post-0700 injection). Hypoglycemia risk is highest during this period due to insulin’s maximum activity, reducing blood glucose. Monitoring at 1100 is critical to detect and treat low glucose, preventing symptoms like tremors or seizures.

Choice D reason: At 0715, only 15 minutes post-NPH insulin, the medication has not reached its onset (1-2 hours). Hypoglycemia is unlikely, as insulin has not significantly lowered glucose. The peak effect at 4-12 hours is when hypoglycemia risk is highest, making 0715 an incorrect time for monitoring.