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
The posterior fontanel, located on the back of the head, usually closes by the age of 2-3 months. By 6 months of age, it is expected to be closed.
By 6 months of age, infants typically do not have their lateral incisors. The primary incisors, which are the central incisors in the lower and upper jaw, usually erupt first around 6-10 months of age.
At around 8 months of age, most infants are able to sit steadily without support. They can maintain an upright sitting position and may even start to reach for objects or play in a sitting position.
At 6 months of age, infants are still in the developmental stage of exploring objects and refining their motor skills. They typically use a palmar grasp, where they grasp objects with their entire hand. The pincer grasp, which involves using the thumb and index finger to pick up small objects, usually develops around 9-10 months of age.
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