A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select two)
Measles, mumps, rubella (MMR)
Rotavirus (RV)
Human papillomavirus (HPV4)
Varicella (VAR)
Diphtheria, tetanus and acellular pertussis (DTaP)
Correct Answer : A,D
The correct answer is a. Measles, mumps, rubella (MMR) and d. Varicella (VAR).
Choice A reason:
Measles, mumps, rubella (MMR): The MMR vaccine is recommended for children at 12-15 months of age. It protects against three serious diseases: measles, mumps, and rubella. The first dose is typically given at 12-15 months, with a second dose at 4-6 years. Measles can cause severe complications such as pneumonia and encephalitis. Mumps can lead to meningitis and hearing loss, while rubella can cause congenital rubella syndrome in pregnant women. Administering the MMR vaccine at the recommended age ensures that the child is protected from these potentially severe diseases.
Choice B reason:
Rotavirus (RV): This vaccine is given to infants at 2, 4, and possibly 6 months of age. It is not typically administered to a 1-year-old child as the series should be completed by 8 months. Rotavirus is a leading cause of severe diarrhea and dehydration in infants and young children. The vaccine is given orally and is highly effective in preventing rotavirus gastroenteritis. However, since the vaccine series is completed by 8 months, it is not appropriate for a 1-year-old child.
Choice C reason:
Human papillomavirus (HPV4): The HPV vaccine is recommended starting at 11-12 years of age. It is not suitable for a 1-year-old child. HPV is a common virus that can lead to certain types of cancers, including cervical cancer. The vaccine is most effective when given before exposure to HPV, which is why it is recommended for preteens. Administering the HPV vaccine to a 1-year-old would not be appropriate as it is not within the recommended age range.
Choice D reason:
Varicella (VAR): The VAR vaccine is recommended for children at 12-15 months of age to protect against chickenpox. A second dose is given at 4-6 years. Chickenpox can cause an itchy rash, fever, and tiredness. In some cases, it can lead to severe skin infections, pneumonia, and encephalitis. Vaccinating at the recommended age ensures that the child is protected from these complications. The first dose at 12-15 months is crucial for building immunity against the varicella virus.
Choice E reason:
Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is given in a series of five doses at 2, 4, 6, 15-18 months, and 4-6 years. The 4th dose is given at 15-18 months, not at 1 year. DTaP protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which causes painful muscle stiffness; and pertussis (whooping cough), which can lead to severe coughing spells and pneumonia. The timing of the doses is crucial for ensuring effective immunity, and the 1-year mark is not one of the recommended times for the DTaP vaccine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because the radial artery is not an ideal site to assess the heart rate in an infant. The radial artery is located on the thumb side of the wrist, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a strong pulse, but it may be difficult to locate or feel in an infant who has a small or weak pulse.
Choice B reason: This choice is incorrect because the carotid artery is not an ideal site to assess the heart rate in an infant. The carotid artery is located on either side of the neck, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a cardiac arrest or shock, but it may be risky to use in an infant who has a fragile neck or airway.
Choice C reason: This choice is incorrect because the brachial artery is not an ideal site to assess the heart rate in an infant. The brachial artery is located on the inner side of the upper arm, and it can be palpated by placing two fingers over it. It may be used for infants or young children who have a blood pressure measurement, but it may be uncomfortable or inaccurate to use for a heart rate assessment.
Choice D reason: This choice is correct because the apex of the heart is an ideal site to assess the heart rate in an infant. The apex of the heart is located at the fifth intercostal space on the left midclavicular line, and it can be auscultated by placing a stethoscope over it. It may be used for infants or young children who have a regular and strong heartbeat, and it may provide the most accurate measurement of the heart rate.
Correct Answer is B
Explanation
Choice A: Tachycardia is not a finding that indicates increased intracranial pressure, but rather a sign of shock, dehydration, or pain. Tachycardia is a fast heart rate, which is more than 160 beats per minute in infants. Tachycardia can occur when the body tries to compensate for low blood pressure, fluid loss, or tissue damage.
Choice B: Increased sleeping is a finding that indicates increased intracranial pressure, as it reflects altered level of consciousness, which is one of the earliest and most sensitive signs of increased intracranial pressure. Increased intracranial pressure can compress the brain tissue and affect its function and responsiveness. Increased sleeping can progress to lethargy, stupor, or coma.
Choice C: Brisk pupillary reaction to light is not a finding that indicates increased intracranial pressure, but rather a normal and expected response. A brisk pupillary reaction to light means that the pupils constrict quickly when exposed to bright light and dilate quickly when exposed to dim light. Brisk pupillary reaction to light indicates intact cranial nerve II (optic) and III (oculomotor).
Choice D: Depressed fontanels are not a finding that indicates increased intracranial pressure, but rather a sign of dehydration or malnutrition. Depressed fontanels are sunken or flat areas on the top or back of an infant's head where the skull bones have not yet fused together. Depressed fontanels can occur when there is insufficient fluid or tissue volume in the body.
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