peds

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. Mother reports that the child is having intermittent episodes of diarrhea. 4. Mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. Mother reports that the child has recently been exposed to an infectious disease.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system. The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing? a. Decorticate posturing b. Decerebrate posturing c. Flexion of the arms and legs d. Normal expected positioning after head injury

a. Decorticate posturing Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet.

An 18 month old child with acquired immunodeficiency syndrome is seen in the clinic for health maintenance. Which of the following vaccines should the nurse anticipate administering. Select all that apply a. DtAP b. Varicella c. MMR d. Influenze vaccine e. Inactivated polio vaccine

a. DtAP d. Influenze vaccine e. Inactivated polio vaccine

The nurse is teaching the parents of a 5 year old child who has just received DtAP; inactivated polio; & MMR vaccines about commonly expected adverse effects. What should be included? Select all that apply a. Fever of 103F (39.5C) b. redness at the injection site c. rash d. anorexia e. prolonged crying f. diarrhea

b. redness at the injection site c. rash d. anorexia

A toddler with croup is given a racemic epinephrine treatment because of increasing respiratory distress. The nurse evaluates the treatment as being effective when the childs a. color is normal b. retractions are less severe c. heart rate 100 bpm d. pulse ox reads 90

b. retractions are less severe it decreases inflammation in the upper airway through vasoconstriction

Which of the following instructions should the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis a. soaking the child in the tub for 30minutes to soften the skin b. using a mild soap followed by patting the skin to dry it c. using an antibacterial soap twice a week d. washing clothes in a strong detergent

b. using a mild soap followed by patting the skin to dry it

A child is scheduled to receive inactivated polio vaccine (IPV), and the nurse preparing to administer the vaccine reviews the child's record. The nurse questions the administration of IPV if which is documented in the child's record? a. Recent recovery from a cold b. A history of frequent respiratory infections c. A history of an anaphylactic reaction to neomycin d. A local reaction at the site of injection of a previous IPV

c. A history of an anaphylactic reaction to neomycin Inactivated poliovirus vaccine (IPV) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? a. Flaccid paralysis of all extremities b. Adduction of the arms at the shoulders c. Rigid extension and pronation of the arms and legs d. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

c. Rigid extension and pronation of the arms and legs Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs.

The clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which route and in which best site? a. Subcutaneously in the gluteal muscle b. Intramuscularly in the deltoid muscle c. Subcutaneously in the outer aspect of the upper arm d. Intramuscularly in the anterolateral aspect of the thigh

c. Subcutaneously in the outer aspect of the upper arm

A 10 year old with a history of bronchial asthma is brought to the emergency department. Which of the following findings requires immediate action? a. increased respiratory effort b. moist loose cough c. absence of wheezing d. prolonged expiratory phase

c. absence of wheezing which indicates a blockage if nothing is heard

The nurse is preparing a plan of care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care knowing that this type of posturing indicates which finding? a. Damage to the pons b. Damage to the midbrain c. Damage to the diencephalon d. A lesion in the cerebral hemisphere

d. A lesion in the cerebral hemisphere

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? a. Eggs b. Penicillin c. Sulfonamides d. A previous dose of hepatitis B vaccine or component

d. A previous dose of hepatitis B vaccine or component

Nursing care of the infant with eczema should focus on which action as a priority nursing intervention? a. keeping the infant content b. maintaining adequate nutrition c. applying antibiotic ointment to lesions d. preventing secondary infection of the lesions

d. preventing secondary infection of the lesions

A male neonate with a 3x5 cm sac in the lumbar region of his back is diagnosed with myelomeningocele. What should the nurse expect to find when expecting this sac a. serosanguinous fluid and fatty tissue b. bits of hair covered by skin c. spinal fluid and meninges d. spinal fluid, nerve tissue, & spinal bony defect

d. spinal fluid, nerve tissue, & spinal bony defect