What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?
Measure the child's temperature and postpone the immunizations if the fever is over 100°F.
Administer the vaccinations as scheduled.
Give the infant the flu vaccination but withhold the others.
Postpone all vaccinations.
The Correct Answer is A
Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.
Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.
Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.
Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Infrequent diaper changes can contribute to diaper rash, but the presence of satellite lesions suggests a yeast infection rather than a simple irritant rash.
Choice B reason: Impetigo, caused by staphylococcal or streptococcal bacteria, typically presents with honey-colored crusts and is not usually associated with satellite lesions.
Choice C reason: The description of bright red scaly plaques and satellite lesions is characteristic of a yeast infection, specifically caused by Candida albicans.
Choice D reason: While urine and feces can irritate the skin and cause diaper rash, the specific clinical findings mentioned point more towards a yeast infection.
Correct Answer is C
Explanation
Choice A reason: This option is incorrect because sickle cell disease is an inherited condition, and one parent having the trait is not sufficient for a child to have the disease.
Choice B reason: This option is also incorrect for the same reason as choice A; both parents must carry the trait for the child to have a chance of inheriting the disease.
Choice C reason: This is the correct choice. Sickle cell disease is inherited when both parents carry the sickle cell trait, giving their child a 25% chance of having the disease.
Choice D reason: This option is incorrect because if only one parent has sickle cell disease and the other has neither the disease nor the trait, the child cannot have sickle cell disease.
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