A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to an adolescent. Which of the following should the nurse identify as a contraindication to administering this vaccine?
Current pregnancy.
Mild ear infection.
Family history of seizures.
Severe peanut allergy.
The Correct Answer is A
Choice A rationale:
Correct Choice. Current pregnancy is a contraindication to administering the measles, mumps, and rubella (MMR) vaccine. The MMR vaccine contains live attenuated viruses, and it is generally contraindicated during pregnancy due to the potential risk to the developing fetus. Pregnant individuals should wait until after giving birth to receive the MMR vaccine.
Choice B rationale:
Mild ear infection is not a contraindication to administering the MMR vaccine. Mild illnesses, such as mild upper respiratory infections or low-grade fevers, are not typically considered contraindications for vaccination. In fact, immunization might be recommended in these cases to ensure protection against preventable diseases.
Choice C rationale:
A family history of seizures is not a contraindication to administering the MMR vaccine. Seizures are not known to be associated with the MMR vaccine. Therefore, a family history of seizures would not preclude an individual from receiving the vaccine.
Choice D rationale:
Severe peanut allergy is not a contraindication to administering the MMR vaccine. Allergies, including severe peanut allergies, are not considered contraindications for the MMR vaccine. Only individuals with a known severe anaphylactic allergy to a vaccine component (such as gelatin or neomycin) would have a contraindication to receiving the vaccine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct answer is choice A. This action is crucial to ensure accurate capillary blood glucose testing. Allowing the skin antiseptic to dry before puncturing the child's finger helps prevent contamination of the blood sample, which can lead to inaccurate results. Wet antiseptic can dilute the blood sample and affect the glucose reading.
Choice B rationale:
This choice is incorrect because placing a cool washcloth on the child's finger is not standard practice before capillary blood glucose testing. While warmth can help increase blood flow and make the puncture process more comfortable, using a cool washcloth is not recommended, as it may constrict blood vessels and make it harder to obtain a sufficient blood sample.
Choice C rationale:
This choice is incorrect because testing the first drop of blood obtained after puncturing the child's finger is not recommended. The first drop of blood can be diluted with interstitial fluid and may not provide an accurate glucose reading. It's important to wipe away the first drop and use the subsequent drop of blood for testing.
Choice D rationale:
This choice is incorrect because puncturing the center of the pad of the child's index finger is not the recommended site for capillary blood glucose testing. The sides of the fingertip contain an adequate blood supply and are less painful for the child. Puncturing the center of the fingertip can be more painful and may not yield a sufficient blood sample.
Correct Answer is B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
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