A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Temperature 37.7° C (99.9° F)
Redness at the injection site
Prolonged crying
Hives on the child's neck
The Correct Answer is D
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
While an oatmeal bath can provide relief from itching, it is not the first step in treating poison ivy exposure. The immediate priority is to remove the plant oils from the skin.
Choice B reason:
Administering an oral corticosteroid may be indicated for severe cases of poison ivy, but it is not the initial step. Removing the plant oils from the skin is the first priority.
Choice C reason:
Applying calamine lotion can help soothe itching, but it is not the first action to take. The priority is to remove any remaining plant oils from the skin.
Choice D reason:
The first action the nurse should take is to remove any remaining plant oils from the skin by flushing the affected area with cold, running water. This helps to prevent further absorption of the irritant.
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
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