What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?
Measure the child's temperature and postpone the immunizations if the fever is over 100°F.
Administer the vaccinations as scheduled.
Give the infant the flu vaccination but withhold the others.
Postpone all vaccinations.
The Correct Answer is A
Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.
Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.
Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.
Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Not crying if parents return and leave again may indicate the child has moved past the initial protest stage but does not necessarily indicate despair.
Choice B reason: This is the correct choice. Lying quietly in bed can be a sign of the despair stage, where the child has given up hope of the parents' return and appears withdrawn.
Choice C reason: Screaming and crying when parents leave is characteristic of the protest stage, not the despair stage.
Choice D reason: Appearing happy and content with staff may indicate the child has reached the detachment stage, which follows despair and involves the child forming new attachments.
Correct Answer is B
Explanation
Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.
Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.
Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.
Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.
Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.
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