MCN 374 EXAM 2: CH 16, 21, 22, 23, 29
A nurse is providing information to a group of new mothers. Which statement best
explains why newborns and young infants are more susceptible to infection?
1. They have high levels of maternal antibodies to diseases to which the mother has
been exposed.
2. They have passive transplacental immunity from maternal immunoglobulin G.
3. They have immune systems that are not fully mature at birth.
4. They have been exposed to microorganisms during the birth process. - Answers :3.
They have immune systems that are not fully mature at birth.
Newborns have a limited storage pool of neutrophils and plasma proteins to defend
against infection. Newborns and young infants high levels of maternal antibodies,
passive transplacental immunity, and exposure to microorganisms during the birth
process are all true but are incorrect answers because they do not explain the
susceptibility of newborns and young infants to infection.
The nurse is discussing ways to treat fever in the home environment to a group of
parents in the community. Which statement is appropriate for the nurse to include in the
presentation?
1. Ibuprofen is the only effective means to reduce fever.
2. If the child requires more than one dose of acetaminophen antibiotics are needed.
3. Purchase a new bottle of acetaminophen for your newborn because it will have
recommended medication concentration.
4. It is not necessary to follow the recommendations on the bottle of ibuprofen as this
will not prevent an overdose for your child. - Answers :3. Purchase a new bottle of
acetaminophen for your newborn because it will have recommended medication
concentration.
The recommendation to purchase a new bottle of acetaminophen due to recommended
medication concentrations is an appropriate statement for the nurse to include in the
teaching session. The other statements are inaccurate or inappropriate for the nurse to
include in the teaching session
,The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis
(DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant
who is 4 months old. The nurse may also give which of immunizations during the same
well-child-care appointment?
1. Var (varicella)
2. TIV (influenza)
3. MMR (measles, mumps, rubella)
4. Haemophilus influenza type B (HIB) - Answers :4. Haemophilus influenza type B
(HIB)
Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age
(four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza
(TIV) vaccine may be given yearly to infants between 6 months and 3 years of age.
Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of
age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for
one dose; for 13 years and older two doses are given, 48 weeks apart.
A mother refuses to have her child be immunized with measles, mumps, and rubella
(MMR) vaccine because she believes that letting her infant get these diseases will help
him fight off other diseases later in life. Which response by the nurse is most
appropriate?
1. Honor her request because she is the parent.
2. Explain that antibodies can fight many diseases.
3. Tell her that not immunizing her infant may protect pregnant women.
4. Explain that if her child contracts measles, mumps, or rubella, there could be very
serious and permanent complications from these diseases. - Answers :4. Explain that if
her child contracts measles, mumps, or rubella, there could be very serious and
permanent complications from these diseases.
Explaining that if her child contracts measles, mumps, or rubella, he could have very
serious and permanent complications from these diseases is correct because measles,
mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain
damage, and deafness. Honoring her request is not correct because the nurse has a
,professional duty to explain that the mothers belief about immunizations is erroneous
and may result in harm to her infant. Explaining that antibodies can fight many diseases
is not correct because the body makes antibodies that are specific to antigens of each
disease. Antibodies for one disease cannot fight another disease. Telling her that not
immunizing her infant may protect pregnant women is not correct because immunizing
the infant with MMR vaccine will help protect pregnant women from contracting rubella
by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be
severely damaged with congenital rubella syndrome.
A parent reports that her school-age child, who has had all recommended
immunizations, had a mild fever one week ago and now has bright red cheeks and a
lacy red maculopapular rash on the trunk and arms. Which disease process does the
nurse suspect based on the parents description?
1. Chicken pox (varicella)
2. German measles (rubella)
3. Roseola (exanthem subitum)
4. Fifth disease (erythema infectiosum) - Answers :4. Fifth disease (erythema
infectiosum)
Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign.
Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to
the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella
(German measles) are unlikely if the child has had all recommended immunizations.
The rash of varicella progresses from papules to vesicles to pustules. The rash of
rubella is a pink maculopapular rash that begins on the face and progresses downward
to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with
a high fever followed by a pale pink rash starting on the trunk and spreading to the face,
neck, and extremities.
The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis)
immunization for a 6-month-old infant. To administer this injection safely, the nurse
chooses which needle, size and length, injection type, and injection site?
1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal.
3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid.
, 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh. - Answers :1. 25-
gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-
inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-
month-old infant is the anterolateral thigh
Reducing the number of preventable childhood illnesses is a major national goal in
Healthy People 2020. What will the school nurse teach families regarding
immunizations in order to reach this goal?
1. A minor illness with a low-grade fever is a contraindication to receiving an
immunization according to Healthy People 2020.
2. Vaccines should be given one at a time for optimum active immunity in the prevention
of illness and disease.
3. Premature infants and low-birth-weight infants should receive half doses of vaccines
for protection from communicable diseases.
4. It is important to maintain vaccination coverage for recommended vaccines in early
childhood and to maintain them through kindergarten. - Answers :4. It is important to
maintain vaccination coverage for recommended vaccines in early childhood and to
maintain them through kindergarten.
The benefits of vaccines far outweigh the risks from communicable diseases and
resulting complications. A minor illness is not a contraindication to immunization. Giving
vaccines one at a time will result in many missed opportunities. Half doses of vaccines
should not be given routinely to premature and low-birth-weight infants.
A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three
times daily by mouth 10 days for otitis media. Which teaching point will guard against
antibiotic resistance to the disease process?
1. Administer a loading dose for the first dose.
2. Measure the prescribed dose in a household teaspoon.
3. Give the antibiotic for the full 10 days.
A nurse is providing information to a group of new mothers. Which statement best
explains why newborns and young infants are more susceptible to infection?
1. They have high levels of maternal antibodies to diseases to which the mother has
been exposed.
2. They have passive transplacental immunity from maternal immunoglobulin G.
3. They have immune systems that are not fully mature at birth.
4. They have been exposed to microorganisms during the birth process. - Answers :3.
They have immune systems that are not fully mature at birth.
Newborns have a limited storage pool of neutrophils and plasma proteins to defend
against infection. Newborns and young infants high levels of maternal antibodies,
passive transplacental immunity, and exposure to microorganisms during the birth
process are all true but are incorrect answers because they do not explain the
susceptibility of newborns and young infants to infection.
The nurse is discussing ways to treat fever in the home environment to a group of
parents in the community. Which statement is appropriate for the nurse to include in the
presentation?
1. Ibuprofen is the only effective means to reduce fever.
2. If the child requires more than one dose of acetaminophen antibiotics are needed.
3. Purchase a new bottle of acetaminophen for your newborn because it will have
recommended medication concentration.
4. It is not necessary to follow the recommendations on the bottle of ibuprofen as this
will not prevent an overdose for your child. - Answers :3. Purchase a new bottle of
acetaminophen for your newborn because it will have recommended medication
concentration.
The recommendation to purchase a new bottle of acetaminophen due to recommended
medication concentrations is an appropriate statement for the nurse to include in the
teaching session. The other statements are inaccurate or inappropriate for the nurse to
include in the teaching session
,The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis
(DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant
who is 4 months old. The nurse may also give which of immunizations during the same
well-child-care appointment?
1. Var (varicella)
2. TIV (influenza)
3. MMR (measles, mumps, rubella)
4. Haemophilus influenza type B (HIB) - Answers :4. Haemophilus influenza type B
(HIB)
Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age
(four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza
(TIV) vaccine may be given yearly to infants between 6 months and 3 years of age.
Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of
age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for
one dose; for 13 years and older two doses are given, 48 weeks apart.
A mother refuses to have her child be immunized with measles, mumps, and rubella
(MMR) vaccine because she believes that letting her infant get these diseases will help
him fight off other diseases later in life. Which response by the nurse is most
appropriate?
1. Honor her request because she is the parent.
2. Explain that antibodies can fight many diseases.
3. Tell her that not immunizing her infant may protect pregnant women.
4. Explain that if her child contracts measles, mumps, or rubella, there could be very
serious and permanent complications from these diseases. - Answers :4. Explain that if
her child contracts measles, mumps, or rubella, there could be very serious and
permanent complications from these diseases.
Explaining that if her child contracts measles, mumps, or rubella, he could have very
serious and permanent complications from these diseases is correct because measles,
mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain
damage, and deafness. Honoring her request is not correct because the nurse has a
,professional duty to explain that the mothers belief about immunizations is erroneous
and may result in harm to her infant. Explaining that antibodies can fight many diseases
is not correct because the body makes antibodies that are specific to antigens of each
disease. Antibodies for one disease cannot fight another disease. Telling her that not
immunizing her infant may protect pregnant women is not correct because immunizing
the infant with MMR vaccine will help protect pregnant women from contracting rubella
by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be
severely damaged with congenital rubella syndrome.
A parent reports that her school-age child, who has had all recommended
immunizations, had a mild fever one week ago and now has bright red cheeks and a
lacy red maculopapular rash on the trunk and arms. Which disease process does the
nurse suspect based on the parents description?
1. Chicken pox (varicella)
2. German measles (rubella)
3. Roseola (exanthem subitum)
4. Fifth disease (erythema infectiosum) - Answers :4. Fifth disease (erythema
infectiosum)
Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign.
Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to
the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella
(German measles) are unlikely if the child has had all recommended immunizations.
The rash of varicella progresses from papules to vesicles to pustules. The rash of
rubella is a pink maculopapular rash that begins on the face and progresses downward
to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with
a high fever followed by a pale pink rash starting on the trunk and spreading to the face,
neck, and extremities.
The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis)
immunization for a 6-month-old infant. To administer this injection safely, the nurse
chooses which needle, size and length, injection type, and injection site?
1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
2. 22-gauge, 1/2-inch needle; IM (intramuscular); ventrogluteal.
3. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid.
, 4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh. - Answers :1. 25-
gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh.
The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8- to 3/4-
inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-
month-old infant is the anterolateral thigh
Reducing the number of preventable childhood illnesses is a major national goal in
Healthy People 2020. What will the school nurse teach families regarding
immunizations in order to reach this goal?
1. A minor illness with a low-grade fever is a contraindication to receiving an
immunization according to Healthy People 2020.
2. Vaccines should be given one at a time for optimum active immunity in the prevention
of illness and disease.
3. Premature infants and low-birth-weight infants should receive half doses of vaccines
for protection from communicable diseases.
4. It is important to maintain vaccination coverage for recommended vaccines in early
childhood and to maintain them through kindergarten. - Answers :4. It is important to
maintain vaccination coverage for recommended vaccines in early childhood and to
maintain them through kindergarten.
The benefits of vaccines far outweigh the risks from communicable diseases and
resulting complications. A minor illness is not a contraindication to immunization. Giving
vaccines one at a time will result in many missed opportunities. Half doses of vaccines
should not be given routinely to premature and low-birth-weight infants.
A toddler client with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three
times daily by mouth 10 days for otitis media. Which teaching point will guard against
antibiotic resistance to the disease process?
1. Administer a loading dose for the first dose.
2. Measure the prescribed dose in a household teaspoon.
3. Give the antibiotic for the full 10 days.
