a nurse is preparing to administer a vaccine to a child who has hemophilia which of the following actions should the nurse take
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Nursing Elites

ATI RN

RN Pediatric Nursing 2023 ATI

1. A healthcare professional is preparing to administer a vaccine to a child who has hemophilia. Which of the following actions should the healthcare professional take?

Correct answer: B

Rationale: Administering the vaccine intramuscularly to a child with hemophilia is preferred to reduce the risk of bleeding. Hemophiliac individuals have a decreased ability to form blood clots, and administering vaccines intramuscularly reduces the risk of bleeding compared to subcutaneous administration. Using an appropriate needle length and applying pressure to the site post-injection are important steps, but choosing the intramuscular route is crucial in this case to minimize bleeding complications.

2. A child receives a vaccine for MMR. Six hours after the injection, the child�s parent reports local soreness, erythema, lethargy, and a fever of 101�F to a nurse. Which action should the nurse take?

Correct answer: A

Rationale: Low-grade fever, malaise, and muscle aches are common reactions. Acetaminophen usually alleviates these problems. MMR is a live vaccine but it is attenuated or completely avirulent and does not cause measles in healthy children, only immunocompromised children.

3. Which type of play involves actions such as looking and touching the mother's face, putting hands in one's mouth, and responding to familiar people?

Correct answer: A

Rationale: Exploratory play is characterized by exploring sensory experiences and learning about the environment. In this type of play, infants engage in activities like looking, touching, and responding to familiar stimuli to understand the world around them.

4. The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child?

Correct answer: A

Rationale: Isotonic dehydration requires the administration of normal saline to restore fluid balance.

5. A healthcare provider is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the healthcare provider?

Correct answer: D

Rationale: In hyperkalemia, cardiac arrhythmias are the most critical and life-threatening manifestation that requires immediate intervention. Hyperkalemia can lead to dangerous heart rhythm disturbances, potentially resulting in cardiac arrest. Prompt treatment is essential to stabilize the heart rhythm and prevent life-threatening complications. Hyperthermia, respiratory distress, and seizures are not typically associated with hyperkalemia and should be addressed, but cardiac arrhythmias pose the most urgent risk to the patient's life.

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