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 A
Explanation
Choice A reason: This is the correct choice. Rheumatic fever is often preceded by an upper respiratory infection caused by group A Streptococcus, which can lead to a sore throat.
Choice B reason: Chest trauma and a fractured rib are not related to the development of rheumatic fever.
Choice C reason: Although a pre-existing heart defect can increase the risk of complications, it is not the cause of rheumatic fever.
Choice D reason: A decreasing appetite over several months is not specifically indicative of rheumatic fever.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
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