The nurse is instructing the parents of a 5-year-old child receiving a MMR vaccine about possible serious reactions. Which of the following is considered a serious reaction? SELECT ALL THAT APPLY

Prolonged seizure

Decreased level of consciousness

Low grade fever

Fussiness and crying

Answer and Explanation

Correct Answer : A,B

A. Prolonged seizures are a serious reaction and require immediate medical attention.
B. Decreased level of consciousness is a serious reaction and requires immediate medical attention.
C. Low grade fever is a common and mild reaction to vaccines.
D. Fussiness and crying are common and mild reactions to vaccines.
E. Redness at the site is a common and mild reaction to vaccines.

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Correct Answer is C

Explanation

A. Documenting the information without taking action is inappropriate as lack of drainage could indicate a serious complication.
B. Encouraging the child to cough and deep breathe might be beneficial, but immediate reporting of this finding is critical.
C. Lack of drainage from the chest tubes following cardiac surgery can be life-threatening, indicating possible cardiac tamponade or tube occlusion. Immediate reporting is necessary for prompt intervention.
D. Assisting the child to a sitting position is not the priority; immediate evaluation by the healthcare team is required.

A. Elevated BUN and Creatinine, decreased H & H decreased platelet count B. Hematuria, decreased BUN and elevated Creatinine, negative ASO titer C. Gross hematuria, proteinuria, increased BUN and Creatinine, decreased Sed Rate D. Elevated BUN and Creatinine, Urine specific gravity of 1.030, positive ASO titer

Correct Answer is D

Explanation

A. Decreased H & H and platelet count are not typical findings in glomerulonephritis.
B. Decreased BUN is not expected; BUN typically increases due to impaired kidney function.
C. Decreased Sed Rate is not expected; Sed Rate may increase due to inflammation.
D. Elevated BUN and Creatinine indicate impaired kidney function. Urine specific gravity of 1.030 indicates concentrated urine, and a positive ASO titer suggests a recent streptococcal infection, which is associated with glomerulonephritis.

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The nurse is instructing the parents of a 5-year-old child receiving a MMR vaccine about possible serious reactions. Which of the following is considered a serious reaction? SELECT ALL THAT APPLY

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a preschool aged child immediately following an open repair of a Ventricular Septal Defect. There has been no drainage from the mediastinal chest tubes in the last 2 hours. Based on this finding what will be the nurse's priority intervention?

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