The nurse monitors a young child following routine immunizations for which of the following indications of a severe reaction?
a. crying for 30 minutes following immunization.
b. temperature elevation of 100 degrees.
c. redness, swelling, and discomfort at the injection site.
d. high-pitched, shrill crying.
ANS: D
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A Incorrect: If not premedicated with EMLA and ibuprofen or acetaminophen, this would be a common response.
B Incorrect: This is a common response.
C Incorrect: This is a common response.
D Correct: This indicates a severe neurological reaction.
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