A nurse is caring for a 6-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?

New onset of seizure disorder in the child's sibling

Evidence of sensitivity to egg antigens

Afebrile otitis media

Temperature of 40.5° C (104.9° F) after last DTaP

Answer and Explanation

The Correct Answer is D

A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.

B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.

C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.

D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.

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Correct Answer is A

Explanation

A. Ribbon Like, foul-smelling stools: Hirschsprung disease is characterized by a lack of nerve cells in parts of the colon, leading to obstruction and resulting in narrow, ribbon-like stools due to the passage through a narrowed section of bowel.

B. Chronic hunger: This is not typical for Hirschsprung disease. Children may actually have a poor appetite due to discomfort and constipation.

C. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis, not Hirschsprung disease.

D. Rigid abdomen: While abdominal distention can occur due to severe constipation and fecal impaction, a rigid abdomen is more indicative of a more acute or severe abdominal condition, such as peritonitis or severe bowel obstruction.

A. Maintain medical asepsis during dressing changes. B. Administer pain medication 30 min to 1 hour before physical therapy. C. Allow the child to set her own schedule for care. D. Provide low-calorie snacks.

Correct Answer is B

Explanation

A. Maintain medical asepsis during dressing changes: While cleanliness is important, aseptic (sterile) technique is typically required for burn care to prevent infection.

B. Administer pain medication 30 min to 1 hour before physical therapy: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.

C. Allow the child to set her own schedule for care: A structured schedule is necessary to ensure regular treatment and care for burns.

D. Provide low-calorie snacks: High-calorie, protein-rich foods are necessary to meet increased metabolic demands for healing.

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A nurse is caring for a 6-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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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