A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?
"My child has some swelling around her eyelids and mouth."
"My child has a temperature of 100.7 degrees Fahrenheit."
"My child only ate 2 ounces during her last feeding."
"My child cries when I touch the area where she received the shot.".
The Correct Answer is A
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ensuring the infant bottle feeds for 45 minutes is not recommended for an infant with heart failure. Prolonged feeding sessions can lead to increased fatigue and stress on the infant's cardiovascular system, exacerbating the heart failure symptoms.
Choice B rationale:
Administering digoxin for a pulse of 70/min is not appropriate. Digoxin is commonly used in heart failure cases to improve cardiac contractility and reduce heart rate. However, giving digoxin solely based on the heart rate without considering other factors can lead to potential overdose and adverse effects.
Choice C rationale:
(Correct Choice) Allowing for frequent rest periods is crucial in the plan of care for an infant with heart failure. Infants with heart failure often experience fatigue and difficulty feeding due to compromised cardiac function. Allowing them to rest between activities helps conserve energy and supports their overall well-being.
Choice D rationale:
Maintaining the infant in a supine position is not the best choice for an infant with heart failure. While the supine position is recommended for safe sleep to reduce the risk of sudden infant death syndrome (SIDS), it may not be optimal for an infant with heart failure. An inclined position may be more suitable to alleviate potential respiratory distress.
Correct Answer is C
Explanation
Choice A rationale:
"I should start by feeding my baby 3 tablespoons of solid food." At 6 months of age, infants are typically just beginning to transition to solid foods. Starting with 3 tablespoons of solid food might be overwhelming and inappropriate for the infant's digestive system. Introducing small amounts and gradually increasing the volume allows the infant to adapt to the new textures and flavors.
Choice B rationale:
"I should limit my baby to 8 ounces of juice per day." Juice consumption should be limited for infants. Juice offers little nutritional value and can contribute to excessive calorie intake, leading to potential weight gain and tooth decay. At 6 months, the primary source of nutrition should still be breast milk or formula, and the introduction of solid foods is meant to complement, not replace these sources.
Choice C rationale:
"I should introduce a new solid food to my baby every five to seven days." This statement indicates an understanding of the recommended approach for introducing solid foods to an infant. Introducing a new food every five to seven days allows the parent to monitor for any potential allergic reactions or sensitivities. This gradual approach helps identify specific foods that the infant may not tolerate well.
Choice D rationale:
"I should sweeten my baby's food with a teaspoon of honey." This statement is incorrect and potentially dangerous. Honey should not be given to infants under 12 months of age due to the risk of infant botulism, a serious and potentially fatal illness. Honey can contain spores of Clostridium botulinum bacteria, which can multiply and produce toxins in an infant's immature digestive system. It's important to avoid honey until the child is older to ensure their safety.
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