Practice Question
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Answer Choices:
Correct Answer:
Hives on the child's neck.
Rationale:
⚠️ Hives (urticaria) on the neck or any part of the body after a hepatitis B immunization can indicate an allergic reaction or anaphylaxis, which is a life-threatening emergency.
⚠️ Early signs of anaphylaxis often include hives, itching, swelling, and respiratory symptoms, and require immediate intervention (e.g., epinephrine, airway support).
⚠️ The other findings—redness at the injection site, mild fever, and prolonged crying—are common, expected reactions to vaccination and are not immediately life-threatening.
⚠️ Prompt recognition of hives allows for early treatment and prevention of progression to more severe symptoms like airway obstruction or shock.
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This question is from ATI LPN Pediatric Nursing~2021 which contains 53 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Pediatrics
- Answer Choices: 4