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 B
Explanation
While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn.
It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
Correct Answer is B
Explanation
At 10 months of age, most infants should be able to sit steadily without support. If the infant is unable to sit without support or shows difficulty maintaining balance while sitting, it may indicate a developmental delay or potential motor coordination issues. It is important to report this finding to the healthcare provider for further evaluation and appropriate intervention if necessary.
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