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:
Tinnitus (ringing in the ears) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice B reason:
Pruritus (itching) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice C reason:
Polyuria (excessive urination) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice D reason:
Abdominal pain is a common symptom of a vaso-occlusive crisis in sickle cell anemia. This pain is due to the obstruction of blood flow in the small vessels of the abdomen, leading to tissue
ischemia and pain.
Correct Answer is D
Explanation
Choice A reason:
Bryant traction is used in infants with congenital hip dysplasia. It is not a form of skin traction for lower extremity fractures in adolescents.
Choice B reason:
Cervical skin traction is used for cervical spine injuries or surgeries, not for lower extremity fractures.
Choice C reason:
Dunlop traction is used for fractures of the humerus.
Choice D reason:
Buck extension traction is applied to the lower leg and uses a boot on the affected leg with weights to provide traction. It is commonly used for lower extremity fractures in adolescents.
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