A 4-month-old infant comes to the well-baby clinic to receive the recommended vaccines for this age. The nurse questions the parents about reactions from the first vaccinations
Which of the following reactions would indicate a need for further evaluation before administering the next set of vaccinations? a. A mild fever and redness at injection site
b. Fussiness, decrease in appetite
c. Mild swelling at the injection site
d. Fever of greater than 104.8° F or above within 48 hours of administration
D
A fever of 104.8° F or greater could indicate a serious reaction and should be further investigated. The other symptoms are normal reactions to vaccine.
You might also like to view...
Which of the following statements about sampling in qualitative research is true?
A) Convenience sampling is considered the most appropriate method of selecting sample members. B) Larger samples are considered more rigorous than smaller samples. C) Using randomness in the sampling process is desirable. D) The type of sampling approach can change and evolve over the course of data collection.
A child with poorly developing bones and teeth should be assessed for adequate intake and use of vitamin
a. D. c. C. b. K. d. B complex.
Which assessment data indicates to the nurse that a 10-year-old child is obese?
A) A body mass index at or below the 95th percentile on the CDC growth chart for a child of the same age and sex. B) A body mass index at or above the 95th percentile on the CDC growth chart for a child of the same age and sex. C) A body mass index at or below the 85th percentile on the CDC growth chart for a child of the same age and sex. D) A body mass index in the 100th percentile on the CDC growth chart for a child of the same age and sex.
A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action?
A. Recheck the vital signs in 1 hour B. Notify the nurse-midwife of the findings C. Continue collecting subjective and objective data D. Document the findings in the client's medical record