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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Modeling clay: Correct. This is appropriate for a 4-year-old, helping with fine motor skills and creativity.
B. Brightly-colored mobile: Incorrect. More suitable for infants who are visually stimulated by simple, moving objects.
C. 100-piece jigsaw puzzle: Incorrect. Too complex for a 4-year-old; age-appropriate puzzles typically have fewer pieces.
D. Checkerboard and checkers: Incorrect. This is better suited for older children who understand rules and strategies.
Correct Answer is C
Explanation
A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.
B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.
C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.
D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.
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