A nurse is evaluating a client who received an immunization for tetanus one week ago.
The client reports pain and swelling at the injection site, low-grade fever, and body aches.
Which of the following responses should the nurse make?
“These are signs of an allergic reaction to the vaccine.”
“These are normal inflammatory responses to the vaccine.”
“These are signs of an active infection with tetanus.”
“These are adverse effects of preservatives in the vaccine.”.
The Correct Answer is B
These are normal inflammatory responses to the vaccine.
The tetanus vaccine protects people from the bacteria that cause tetanus, a serious disease that causes muscle stiffness and spasms.
The vaccine stimulates the body’s immune system to produce antibodies against the bacteria. Sometimes, this immune response can cause mild symptoms such as pain, redness, swelling, fever, headache, or tiredness.
These are not signs of an infection or an allergic reaction, but rather the body’s way of building immunity.
Choice A is wrong because an allergic reaction to the vaccine would cause more severe symptoms such as hives, swelling of the face or throat, difficulty breathing, or shock.
These symptoms would usually occur within minutes or hours of getting the vaccine and require immediate medical attention.
Choice C is wrong because these are not signs of an active infection with tetanus.
Tetanus is a rare but potentially fatal disease that causes muscle spasms and paralysis.
It is caused by bacteria that enter the body through wounds or cuts. The symptoms of tetanus usually appear several days or weeks after exposure and include lockjaw, stiffness of the neck and abdomen, difficulty swallowing, fever, sweating, and seizures.
The tetanus vaccine prevents the disease by creating immunity before exposure.
Choice D is wrong because these are not adverse effects of preservatives in the vaccine.
Preservatives are substances that prevent contamination and spoilage of vaccines. The most common preservative used in tetanus vaccines is thimerosal, a mercury-based compound that has been proven to be safe and effective.
There is no evidence that thimerosal causes autism or any other health problems.
Some people may have a sensitivity to thimerosal or other ingredients in the vaccine, but this is very rare and would cause an allergic reaction as described in choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Discontinue the oxytocin (Pitocin) infusion.This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate alate deceleration, which is a sign offetal hypoxia.Oxytocin is a drug that stimulates uterine contractions and can causeuterine hyperstimulation, which reduces blood flow to the placenta and the fetus.By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.
Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused.Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.
Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time.The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.
Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.
Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting
Correct Answer is A
Explanation
Absent Moro reflex on the affected side indicates a possible injury to the brachial plexus, which is the nerve network that controls the movements and sensations of the shoulder, arm, hand and fingers.Shoulder dystocia can cause brachial plexus injuries when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery.
Choice B is wrong because flaccid paralysis of both lower extremities is not a common complication of shoulder dystocia.
It could be a sign of spinal cord injury or other neurological disorders.
Choice C is wrong because facial asymmetry when crying or smiling is a sign of facial nerve palsy, which can occur due to compression of the facial nerve during delivery.
It is not specific to shoulder dystocia.
Choice D is wrong because inability to suck or swallow is not a typical sign of shoulder dystocia.
It could be caused by other factors such as prematurity, neurological problems, or congenital anomalies.
Normal ranges for Moro reflex are present at birth and disappear by 4 to 6 months of age.
Normal ranges for facial nerve function are symmetrical movements of both sides of the face.
Normal ranges for sucking and swallowing are coordinated and effective feeding within the first hour after birth.
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