A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Temperature 37.7° C (99.9° F)
Redness at the injection site
Prolonged crying
Hives on the child's neck
The Correct Answer is D
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
Correct Answer is B
Explanation
Choice A reason:
Increased urinary output is not typically associated with heart failure. In fact, heart failure often leads to decreased urine output due to decreased cardiac output.
Choice B reason:
Tachycardia (rapid heart rate) is a common manifestation of heart failure in infants. The heart compensates for decreased cardiac output by beating faster.
Choice C reason:
Bounding peripheral pulses are not typically associated with heart failure. In fact, weak peripheral pulses may be a sign of decreased cardiac output.
Choice D reason:
Increased blood pressure is not typically associated with heart failure in infants. Instead, infants with heart failure may have low or normal blood pressure.
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