A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunization to 15-month-old toddler. Which of the following findings is a contraindication for this immunization?
The child has a congenital immunodeficiency.
The child is currently taking antibiotics for otitis media.
The child has a cough and a temperature of 37.7° C (99.9" F)
The child's temperature after the last set of immunizations was 38.3 C(101)
The Correct Answer is A
Children with congenital immunodeficiencies have compromised immune systems and may not be able to mount an adequate immune response to the vaccine. Administering live vaccines, such as MMR, to these children can potentially cause severe complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The appropriate pain rating scale to use for a 2-month-old infant is the FLACC (Face, Legs, Activity, Cry, Consolability) scale. The FLACC scale is commonly used for infants and young children who are unable to self-report their pain. It assesses facial expression, leg movement, activity level, cry, and ability to be consoled. Each category is scored on a scale of 0 to 2, and the total score provides an indication of the infant's pain level.
The PANAD scale and OUCHER scale are more commonly used for older children, while the FACE scale is specific to assessing pain in individuals with cognitive impairments.
Correct Answer is B
Explanation
These behaviors suggest that the child is experiencing distress or discomfort in response to the separation from the mother and the hospital environment.
Anxiety reactions are common in toddlers who are hospitalized or experience separation from their primary caregivers. It is a normal response to unfamiliar and potentially stressful situations. Toddlers at this age are still developing a sense of security and trust in their environment, and being in the hospital can disrupt their routine and comfort.
It is important for the nurse to provide a calm and supportive environment for the toddler, offering reassurance and comfort. The nurse can engage in activities that promote a sense of security and provide opportunities for the toddler to express their emotions and fears, such as through play or comforting rituals.
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