The nurse is teaching a prenatal class about infant care. Under which circumstances should the nurse emphasize that parents should call their healthcare provider immediately?
1. Child 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F)
2. Child under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F)
3. Child difficult to awaken and has a pulsing fontanel
4. Child has purple spots on the skin and is lethargic.
5. Child has a stiff neck and has been irritable for three days.
Correct Answer: 2,3,4,5
Rationale: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.
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