A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?

Choice A reason: This choice is incorrect because a 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F) is not the most urgent case to assess. Roseola is a viral infection that causes a rash on the trunk and limbs, followed by a high fever that lasts for several days. It usually affects infants and young children and is self-limiting.
The fever can be managed by giving antipyretics such as acetaminophen or ibuprofen, and by providing fluids and comfort measures. The fever does not indicate any serious complication or threat to life.

Choice B reason: This choice is incorrect because a 4-year-old child who has asthma and an O2 sat of 97% is not the most urgent case to assess. Asthma is a chronic respiratory condition that causes inflammation and narrowing of the airways, leading to wheezing, coughing, chest tightness, or shortness of breath. It may be triggered by allergens, irritants, exercise, or infections. The O2 sat is a measure of oxygen saturation in the blood, which indicates how well oxygen is delivered to the tissues. A normal O2 sat range is 95% to 100%, so an O2 sat of 97% indicates that the child has adequate oxygenation and is not in respiratory distress.

Choice C reason: This choice is correct because a 10-year-old child who has sickle cell anemia and reports severe chest pain is the most urgent case to assess. Sickle cell anemia is a genetic disorder that causes the red blood cells to become sickle-shaped and clump together, blocking the blood flow and oxygen delivery to the organs and tissues. It may cause severe pain in the chest, abdomen, joints, or bones, as well as symptoms such as pallor, jaundice, fatigue, or shortness of breath. Severe chest pain may indicate acute chest syndrome, which is a life-threatening complication of sickle cell anemia that involves infection or infarction of the lungs. It may cause fever, cough, hypoxia, or respiratory failure. Therefore, assessing and treating this child is a priority to prevent further damage and death.

Choice D reason: This choice is incorrect because a 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 is not the most urgent case to assess. Diabetes insipidus is a rare disorder that affects the balance of fluids in the body. It causes the kidneys to produce large amounts of dilute urine, leading to polyuria, polydipsia, dehydration, or electrolyte imbalance. It may be caused by a deficiency of antidiuretic hormone (ADH) or a resistance to its action. The urine specific gravity is a measure of urine concentration, which indicates how well the kidneys are functioning. A normal urine specific gravity range is 1.005 to 1.030, so a urine specific gravity of 1.016 indicates that the child has normal urine concentration and is not dehydrated.

Choice A reason: This choice is correct because providing a latex-free environment is an essential intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Spina bifida is a congenital defect in which the spinal cord and its coverings do not close properly, resulting in a protrusion of the meninges (meningocele) or the meninges and spinal cord (myelomeningocele). Children who have spina bifida are at a high risk of developing a latex allergy, which can cause severe reactions such as anaphylaxis or death. Therefore, avoiding exposure to latex products such as gloves, catheters, balloons, or bandages is crucial to prevent complications.

Choice B reason: This choice is incorrect because initiating contact precautions is not necessary for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Contact precautions are infection control measures that prevent the transmission of microorganisms that can be spread by direct or indirect contact with the client or their environment. They may be indicated for clients who have multidrug-resistant organisms, clostridium difficile, or scabies, but they are not required for clients who have spina bifida unless they have a concurrent infection.

Choice C reason: This choice is incorrect because limiting visitors to immediate family members is not indicated for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Limiting visitors may be indicated for clients who have immunosuppression, isolation, or terminal illness, but it may not be beneficial for clients who have spina bifida. Allowing visitors may provide emotional and social support for the client and their family, as long as they follow standard precautions and do not pose any risk of infection or injury.

Choice D reason: This choice is incorrect because maintaining the infant in the supine position is not an appropriate intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac.
Maintaining the infant in the supine position may cause pressure or trauma to the sac, which can lead to rupture, infection, or nerve damage. Therefore, positioning the infant in a prone or side-lying position with the hips flexed and knees abducted can help to protect the sac and prevent complications.