The nurse is teaching a mother about caring for her 6-month-old infant following the administration of routine immunizations. Which finding should the nurse explain to the mother to report to the healthcare provider?
Poor appetite and frequent crying.
Redness at the injection sites.
Clear nasal drainage and cough.
Axillary temperature of 100.8° F (38.2° C).
The Correct Answer is C
Choice A reason: Poor appetite and frequent crying are common post-immunization reactions in infants. These symptoms typically resolve within 24–48 hours and do not indicate a serious adverse event unless they persist or worsen.
Choice B reason: Redness at the injection site is a normal inflammatory response and usually resolves without intervention. It is not considered a reportable adverse reaction unless accompanied by swelling, induration, or signs of infection.
Choice C reason: Clear nasal drainage and cough may indicate a concurrent viral infection or an atypical response to the vaccine. These symptoms are not typical post-vaccine effects and may warrant further evaluation to rule out respiratory illness or allergic reaction.
Choice D reason: An axillary temperature of 100.8°F (38.2°C) is a mild fever and a common post-vaccination response. It does not require reporting unless it exceeds 104°F (40°C) or is accompanied by other concerning symptoms such as seizures or lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While the chef salad includes lean protein, the bacon and ranch dressing add saturated fats and sodium. Apple pie is high in sugar and refined carbohydrates, which may lead to energy crashes and poor concentration.
Choice B reason: A cheeseburger with fries and cola is high in saturated fats, sodium, and sugar. This combination can impair cognitive performance and contribute to fatigue and poor mood regulation during exams.
Choice C reason: Tuna casserole offers protein and vegetables, and the apple adds fiber. However, casseroles often contain creamy sauces and processed ingredients that may be high in sodium and fat. Crackers may also be refined and low in nutritional value.
Choice D reason: Fruit salad and chicken vegetable soup provide a balance of vitamins, lean protein, and fiber. Tea offers hydration and mild stimulation without excess sugar. This combination supports sustained energy and mental clarity.
Correct Answer is B
Explanation
Choice A reason: Hand hygiene is important for preventing transmission of infectious agents, but it does not help differentiate the cause of acute eye symptoms. It is more relevant in infection control than in immediate assessment.
Choice B reason: Asking about eye discharge helps determine the nature of the condition—whether it is infectious (e.g., bacterial conjunctivitis), inflammatory, or allergic. Discharge type (purulent, watery, mucous) provides diagnostic clues essential for treatment.
Choice C reason: Immunization status is relevant for systemic disease prevention but not immediately helpful in evaluating acute eye symptoms. It does not guide the clinical decision-making for localized eye inflammation.
Choice D reason: New medications can cause allergic reactions or side effects, but this is less likely than an infectious or inflammatory cause in the context of pain, redness, and swelling. It is a secondary consideration after assessing local symptoms.
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