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 A
Explanation
Choice A reason:
Children with cystic fibrosis often have increased calorie needs due to the extra energy required to breathe and the malabsorption of nutrients. A diet that is high in both protein and calories
helps meet these increased energy needs.
Choice B reason:
While a higher fat intake may be beneficial for some children with cystic fibrosis, it should not be at the expense of protein intake, which is also crucial for growth and development.
Choice C reason:
A diet that is low in both protein and calories would not be appropriate for a child with cystic fibrosis, as it may not provide sufficient energy and nutrients to support growth and
development.
Choice D reason:
A diet that is low in carbohydrates and high in fat is not typically recommended for children with cystic fibrosis. They need a balanced diet that includes a variety of macronutrients to meet their
increased energy needs.
Correct Answer is B
Explanation
Choice A reason:
Hopscotch requires a level of coordination and balance that may be challenging for a 2-year-old toddler.
Choice B reason:
Finger painting is a creative and age-appropriate activity for a 2-year-old. It allows them to explore colors and textures while developing fine motor skills.
Choice C reason:
Beginner sports may involve activities that are too complex for a 2-year-old to fully understand and participate in.
Choice D reason:
A 30-piece puzzle may be too advanced for a 2-year-old. They may have difficulty manipulating the small pieces and understanding the concept of assembling the puzzle.
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