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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Administering naloxone is not indicated for a seizure. Naloxone is used to reverse opioid overdose, not treat seizures.

Choice B reason:

Checking inside the child's mouth for bleeding is important after a seizure to ensure there is no injury to the oral cavity.

Choice C reason:

Giving the child a drink of water immediately after a seizure is not a priority intervention. The child may not be able to swallow properly immediately after a seizure.

Choice D reason:

Placing the child's head in a hyperextended position is not a recommended intervention after a seizure. It is important to maintain the child in a safe position and provide appropriate care after the seizure has ended.

A. Connect a bulb attachment to the syringe to deliver the feeding. B. Heat the formula to body temperature. C. Position the child with the head of the bed elevated 15°. D. Instill the feeding if the pH is less than 5.

Correct Answer is C

Explanation

Choice A reason:

Connecting a bulb attachment to the syringe is not a standard method for administering a tube feeding and can potentially lead to complications.

Choice B reason:

Heating the formula to body temperature is not typically necessary and can be potentially dangerous if it leads to overheating.

Choice C reason:

Positioning the child with the head of the bed elevated at 15° helps to prevent aspiration during tube feeding.

Choice D reason:

Instilling the feeding based on pH alone is not a sufficient criterion for administration. Other factors, such as radiographic confirmation of tube placement, should also be considered.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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