A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
New onset of seizure disorder in the child's sibling
Evidence of sensitivity to egg antigens
Afebrile otitis media
Temperature of 40.5° C (104.9° F) after last DTaP
The Correct Answer is D
A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.
B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.
C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.
D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.
B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.
C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.
D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.
Correct Answer is D
Explanation
A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.
B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.
C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.
D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.
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