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

Explanation

Choice A reason:

Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.

Choice B reason:

Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.

Choice C reason:

A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.

Choice D reason:

The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.

A. Give 500 mg acetaminophen PO every 2 hr. B. Administer a 300-mg aspirin suppository. C. Place the child in an ice bath. D. Lower the temperature of the room.

Correct Answer is D

Explanation

Choice A reason:

This is a high dose for a 2 year old child.

Choice B reason:

Aspirin is contraindicated for children with viral infections due to the risk of Reye's syndrome. It should not be administered.

Choice C reason:

Placing the child in an ice bath is an overly aggressive intervention and can lead to hypothermia. It is not recommended.

Choice D reason:

Lowering the temperature of the room is important in reducing external temperature to help cool the baby.

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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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