A 6-month-old infant presents to the clinic for routine immunizations. Prior to this visit, the infant has remained up-to-date with immunizations. The nurse anticipates the infant will need which of the following immunizations recommended at 6 months? Select one that doesn't apply.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Measles, mumps, rubella (MMR) because the MMR vaccine is typically administered around 12-15 months of age, not at 6 months. The MMR vaccine provides protection against these viral infections. Option A) Pneumococcal vaccine is recommended at 2, 4, 6, and 12-15 months, so it would be appropriate at 6 months. Option B) DTaP vaccine is also given at 2, 4, 6, and 12-15 months, making it appropriate for this age group. Option D) Hib vaccine is typically given at 2, 4, 6, and 12-15 months, so it would be indicated at 6 months as well. Educationally, it's crucial for nurses to understand the recommended immunization schedule for pediatric patients to ensure they receive the appropriate vaccines at the right time. This knowledge helps prevent missed opportunities for immunization and ensures optimal protection against vaccine-preventable diseases. Furthermore, understanding the rationale behind each vaccine's timing and purpose enhances the nurse's ability to educate parents and caregivers effectively.

Correct Answer: B

Rationale: In pediatric oncology, children with leukemia are at increased risk for infections due to compromised immune function from the disease itself and the treatment modalities such as chemotherapy. The correct answer is B) Infection. Leukemia affects the production of normal white blood cells, which are crucial for fighting infections. Children undergoing treatment for leukemia often experience neutropenia, a condition characterized by low levels of neutrophils, a type of white blood cell responsible for fighting bacterial and fungal infections. Option A) Hypoglycemia is not directly related to leukemia. While some chemotherapy drugs may cause alterations in blood sugar levels, it is not a primary concern for children with leukemia. Option C) Dehydration is not a common risk specifically associated with leukemia. Although some chemotherapy medications can cause side effects like nausea, vomiting, or diarrhea, leading to dehydration, it is not a direct consequence of leukemia itself. Option D) Cardiac arrhythmias are not a typical risk for children with leukemia. While certain chemotherapy drugs may have cardiotoxic effects, cardiac arrhythmias are not a primary concern in the immediate care of a child with leukemia. Understanding the increased susceptibility to infections in children with leukemia is crucial for nurses caring for these patients. Nurses need to monitor for signs of infection, practice strict infection control measures, and educate patients and families on the importance of preventing infections through good hygiene practices and avoiding exposure to sick individuals. This knowledge is vital for providing safe and effective care to pediatric patients with leukemia.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Ear infection. When a 6-month-old infant is excessively crying, it could be due to an ear infection because the infant may not be able to communicate the pain verbally. Ear infections are common in infants and can cause significant discomfort, leading to increased crying. It is crucial for the nurse to consider this as a potential cause and assess the infant's ears for signs of infection. Option A) Teething pain is a common issue in infants but typically does not cause excessive crying unless accompanied by other symptoms like swollen gums or drooling. Option B) Hunger can be easily ruled out by attempting to feed the infant. Option C) A wet diaper is also easily identifiable and can be ruled out by checking the diaper. In an educational context, it is important for nurses to be able to differentiate between various common causes of infant distress. Understanding the signs and symptoms of different conditions helps nurses provide appropriate care and interventions promptly. This question highlights the significance of thorough assessment and critical thinking in pediatric nursing, especially when dealing with non-verbal patients like infants.

Correct Answer: B

Rationale: The correct answer is B) Rest and hydration. When a child is diagnosed with a viral upper respiratory infection, antibiotics are not effective because antibiotics only work against bacterial infections, not viral ones. Antiviral medications are specifically designed to treat viral infections, but they are not typically used for common upper respiratory infections in children. Corticosteroids may be used in certain cases to reduce inflammation, but they are not the primary treatment for viral upper respiratory infections. In an educational context, it is crucial for nurses to understand the appropriate treatments for different types of infections to provide safe and effective care to pediatric patients. Teaching parents and caregivers about the importance of rest and hydration in managing viral upper respiratory infections helps them support their child's recovery at home. Nurses play a vital role in patient education, promoting healthy behaviors, and ensuring families have the knowledge they need to care for their children during illness.

Correct Answer: C

Rationale: The correct answer is C) Assessing for other signs of infection. When a child presents with a fever, it is crucial to assess for other signs of infection to determine the underlying cause. Fever can be a symptom of various conditions, including infections. By assessing for other signs such as cough, runny nose, rash, or pain, the nurse can gather more information to guide further interventions and treatment. Option A) Administering acetaminophen to reduce fever is important to provide comfort to the child and help reduce fever-related symptoms. However, it is not the priority in this situation. The underlying cause of the fever needs to be identified first. Option B) Encouraging the child to drink fluids is a good practice to prevent dehydration, but it is not the priority when assessing a child with a fever. Dehydration can be a concern but should come after assessing for signs of infection. Option D) Monitoring the fever every hour is important in the ongoing care of the child, but initially, assessing for other signs of infection takes precedence to determine the appropriate course of action. In an educational context, prioritizing nursing interventions based on assessment findings is a fundamental skill in pediatric nursing. Understanding the hierarchy of needs and immediate concerns helps nurses provide efficient and effective care to pediatric patients. By focusing on assessing for signs of infection first, nurses can address the root cause of the fever and tailor their care accordingly.