A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations. Which immunizations will the nurse prepare to administer? (Select all that apply.)

Correct Answer: B

Rationale: A 4-month-old infant who is up to date on routine immunizations would not need the Measles, mumps, and rubella (MMR), Varicella, or Haemophilus influenzae type b (HIB) vaccines at this time. These vaccines are typically administered at older ages based on the recommended immunization schedule.

Correct Answer: C

Rationale: Romberg's test is a neurological test that assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception and vibration sensations. A lumbar injury can affect these dorsal columns, leading to impaired proprioception. Therefore, the Romberg's test would be affected due to the compromised sensory input from the lower extremities. This test usually involves asking the patient to stand with feet together and eyes closed to assess balance and proprioception.

Correct Answer: C

Rationale: The child most likely lost 8 pounds due to a reduction of edema. Acute glomerulonephritis is a condition that can lead to significant fluid retention in the body, causing edema (swelling). When the child was hospitalized and received treatment, such as diuretics, to address the underlying cause of the edema, the excess fluid and weight would be lost. This reduction in edema is the most common reason for weight loss in this scenario, rather than poor appetite, increased potassium intake, or restriction to bed rest.

Correct Answer: B

Rationale: In the scenario of an elderly patient like Mr. Cruz with suspected pulmonary embolism, the nurse would anticipate an order for the immediate administration of heparin. Heparin is an anticoagulant medication that works quickly to prevent the further development of blood clots. It is often used as the initial treatment for pulmonary embolism to prevent existing blood clots from getting larger and reduce the risk of new clots forming. Heparin is preferred over warfarin initially because it has a more rapid onset of action. Warfarin, which is a commonly used anticoagulant for longer-term management, takes several days to reach its full effect and requires monitoring of the prothrombin time (INR). Therefore, in Mr. Cruz's acute situation, heparin would be the most appropriate choice for immediate intervention to address the pulmonary embolism.

Correct Answer: D

Rationale: Paranasal sinuses are considered unfavorable sites in rhabdomyosarcoma staging.