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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Bryant traction is used in infants with congenital hip dysplasia. It is not a form of skin traction for lower extremity fractures in adolescents.
Choice B reason:
Cervical skin traction is used for cervical spine injuries or surgeries, not for lower extremity fractures.
Choice C reason:
Dunlop traction is used for fractures of the humerus.
Choice D reason:
Buck extension traction is applied to the lower leg and uses a boot on the affected leg with weights to provide traction. It is commonly used for lower extremity fractures in adolescents.
Correct Answer is D
Explanation
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
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