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 C
Explanation
Choice A rationale
The Numeric scale is not suitable for an 18-month-old infant as it requires the child to understand numbers and express their pain level accordingly. Infants at this age lack the cognitive ability to accurately use the Numeric scale.
Choice B rationale
The Poker Chip Tool is used for children aged 3 to 4 years and older. It involves the child choosing a number of poker chips to represent their pain level, which an 18-month-old infant cannot comprehend due to their developmental stage.
Choice C rationale
The FLACC Scale (Face, Legs, Activity, Cry, Consolability) is appropriate for infants and young children. It assesses pain based on objective observations of the child’s behavior, making it suitable for an 18-month-old infant who cannot verbally express pain.
Choice D rationale
The Color tool, which involves choosing a color to represent pain intensity, is not appropriate for an 18-month-old infant as they may not have developed the ability to associate colors with pain levels.
Correct Answer is B
Explanation
Choice A rationale
Facial edema is not a typical manifestation of a urinary tract infection (UTI). UTIs primarily affect the urinary system, causing symptoms such as painful urination, increased frequency, and urgency. Facial edema is more commonly associated with kidney issues such as nephrotic syndrome or systemic conditions like heart failure. It is important to look for signs directly related to the urinary system when diagnosing a UTI.
Choice B rationale
Increased temperature, or fever, is a common manifestation of a urinary tract infection, especially in children. Fever occurs as the body's immune response to infection, attempting to fight off the bacteria causing the UTI. Monitoring the child's temperature and other symptoms is crucial in diagnosing and managing UTIs, ensuring appropriate treatment to prevent complications.
Choice C rationale
Muscle twitching is not typically associated with urinary tract infections. Muscle twitching can be caused by electrolyte imbalances, neurological issues, or muscle fatigue. UTIs usually present with symptoms related to the urinary system, such as dysuria, frequency, and abdominal pain. It is essential to focus on urinary symptoms when suspecting a UTI.
Choice D rationale
Moist mucus membranes do not indicate a urinary tract infection. This finding is more related to hydration status and general health. UTIs are characterized by urinary symptoms and systemic signs such as fever. Assessing for signs like dysuria, frequency, urgency, and abdominal discomfort is more relevant in diagnosing a UTI.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.