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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Related Questions
Correct Answer is D
Explanation
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
Correct Answer is B
Explanation
A. Fruity breath odour: This is a sign of diabetic ketoacidosis (DKA), a condition associated with hyperglycemia, not hypoglycaemia.
B. Diaphoresis: Sweating is a common sign of hypoglycemia due to the body's release of adrenaline in response to low blood sugar levels.
C. Dry mucous membranes: This is typically associated with dehydration and hyperglycemia, not hypoglycaemia.
D. Polyuria: Frequent urination is a symptom of hyperglycemia, as the body tries to excrete excess glucose through the urine.
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