A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization.
Which of the following findings is the nurse's priority?
Redness at the injection site.
Temperature 37.7°C (99.9°F).
Hives on the child's neck.
Prolonged crying.
The Correct Answer is C
Choice C rationale
Hives on the child's neck is the priority finding because it can indicate an allergic reaction, which may progress to anaphylaxis. Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention. Hives are often the first sign of an allergic reaction and can quickly escalate to airway obstruction, difficulty breathing, and cardiovascular collapse. Early identification and treatment of an allergic reaction can prevent these severe complications. The nurse should be prepared to administer emergency medications, such as epinephrine, and provide respiratory support if needed.
Choice A rationale
Redness at the injection site is a common and expected local reaction following immunization. It typically resolves on its own without intervention. While it may cause some discomfort, it does not pose an immediate threat to the child's health and is not a priority over signs of a potential allergic reaction.
Choice B rationale
A temperature of 37.7°C (99.9°F) is a mild fever and a common response to immunizations as the body mounts an immune response. It is not usually cause for concern and can be managed with antipyretics if necessary. This mild fever does not indicate an urgent condition compared to the signs of an allergic reaction.
Choice D rationale
Prolonged crying can be a sign of discomfort or pain following an immunization but is not necessarily indicative of a severe reaction. It is important to assess the child's overall condition and provide comfort measures. However, it does not take precedence over signs of an allergic reaction, which require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Flushing the tube with only 2 ml of sterile water after administering all medications may not be sufficient to ensure the tube is completely clear. The recommended amount is usually more to ensure the tube is adequately flushed.
Choice B rationale
Allowing medications to flow into the tube by gravity is the correct method as it helps to ensure that the medications are delivered at a consistent rate without the risk of pushing too fast.
Choice C rationale
Crushing sustained-release tablets is contraindicated as it can alter the medication's release properties, leading to potential overdose or loss of efficacy.
Choice D rationale
Mixing all medications together prior to administration can cause interactions and alter the effectiveness or stability of the medications, which is not recommended.
Correct Answer is A
Explanation
Choice A rationale
New onset lethargy in a child with endocarditis is concerning and could indicate worsening of the infection, possibly leading to heart failure or other complications. This needs immediate assessment and intervention.
Choice B rationale
Erythema of the lips is a common symptom in Kawasaki disease and, while it needs monitoring, it is not typically an immediate emergency.
Choice C rationale
An increased erythrocyte sedimentation rate is an indication of inflammation but is expected in rheumatic fever and does not necessitate immediate intervention.
Choice D rationale
Weak pedal pulses are a characteristic of coarctation of the aorta but are typically a chronic finding that does not require immediate emergency action unless accompanied by other symptoms. .
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