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

Answer and Explanation

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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Correct Answer is ["C","D","E"]

Explanation

Choice A reason:

Tinnitus - Tinnitus (ringing in the ears) is not typically associated with bacterial meningitis. The focus is on central nervous system symptoms and signs of meningeal irritation.

Choice B reason:

Negative Kernig sign - This is a classic sign of meningeal irritation. In bacterial meningitis, the Kernig sign will be positive, indicating resistance and pain upon extension of the knee after flexing the hip.

Choice C reason:

Vomiting - Nausea and vomiting are common symptoms of bacterial meningitis. They are caused by increased intracranial pressure and meningeal irritation.

Choice D reason:

Headache - Headache is a common symptom of bacterial meningitis, often severe and accompanied by other signs of meningeal irritation.

Choice E reason:

Seizures - Seizures can occur in bacterial meningitis due to the inflammation and irritation of the brain.

A. Give pain medications on a schedule. B. Initiate contact isolation. C. Offer clear liquids. D. Maintain strict bed rest.

Correct Answer is A

Explanation

Choice A reason:

Providing pain medication on a schedule is important for managing pain and ensuring the child's comfort, especially after a surgery involving peritonitis.

Choice B reason:

Contact isolation is not typically indicated for a child postoperative for appendicitis unless there is a specific infectious concern. It is not a routine intervention.

Choice C reason:

Offering clear liquids may be appropriate depending on the child's individual recovery and surgeon's orders. However, this should be determined on an individual basis and is not a standard postoperative intervention.

Choice D reason:

Maintaining strict bed rest may not be necessary for all children postoperative for appendicitis. Early mobilization and ambulation are often encouraged to promote recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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