A nurse in a provider's office is preparing to administer immunizations to a 12-year-old client during a well-child visit.
Which of the following immunizations should the nurse plan to administer?

 

Choice A rationale:

Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.

Choice B rationale:

Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.

Choice C rationale:

Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.

Choice D rationale:

Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.

Choice A rationale:

Unable to hold a bottle is a developmental milestone expected at around 6 months of age. This is not a concerning finding for a 5-month-old infant.

Choice B rationale:

The grasp reflex is present in infants until about 6 months of age. Its absence is expected at 5 months and is not a cause for concern.

Choice C rationale:

Rolling from back to abdomen is typically achieved by 5 months of age. However, the inability to do so is not necessarily a red flag at this age, as each infant develops at their own pace.

Choice D rationale:

Head lag refers to the infant's head falling backward when pulled to a sitting position, indicating poor head control. This is a significant developmental red flag at 5 months of age and should be reported to the provider. It might indicate possible neuromuscular issues or developmental delays, requiring further evaluation and intervention.