A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?
"I should not feed my baby anything for 2 hours prior to an immunization."
"I should expect my baby to have a high fever for 24 hours after an immunization."
"My baby will receive the rotavirus immunization orally
"My baby will receive three doses of the meningococcal immunization before kindergarten."
The Correct Answer is C
The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.
There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.
While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.
The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Incident report.
Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.
The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.
The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.
The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.
Correct Answer is B
Explanation
To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I
It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.
Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.
Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.
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