A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
Pneumococcal conjugate vaccine (PCV)
Hepatitis B (HBV)
Haemophilus influenzae type B (Hib)
Measles, mumps, and rubella (MMR)
The Correct Answer is D
A. Pneumococcal conjugate vaccine (PCV): This vaccine is generally completed before the age of 5, so it is not typically administered at this stage.
B. Hepatitis B (HBV): The HBV series is usually completed during infancy and early childhood, so it is not needed at 5 years if the child is up to date.
C. Haemophilus influenzae type B (Hib): Hib is typically completed by 18 months of age and is not required for pre-kindergarten.
D. Measles, mumps, and rubella (MMR): A second dose of MMR is typically required at 4-6 years, aligning with pre-kindergarten vaccination schedules.
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Correct Answer is A
Explanation
A. Aura: An aura is a subjective sensation experienced before a seizure, such as a strange smell, taste, or visual change. It can provide clues about the seizure's origin in the brain, often linked to the temporal lobe.
B. Blood Pressure 90/60: Blood pressure is an objective, measurable sign, not subjective data reported by the child.
C. Oxygenation on room air 97%: Oxygenation levels are objective and do not provide information about seizure origin.
D. Temperature 38 degrees Celsius: Temperature is objective and does not help localize the seizure's origin in the brain.
Correct Answer is B
Explanation
A. Apply oxygen by nasal cannula: Applying oxygen can be beneficial but is not the immediate priority during an active seizure. Protecting the airway comes first.
B. Turn the client to a lateral position: This action prevents aspiration by keeping the airway clear if the client vomits or has excessive secretions.
C. Administer an anticonvulsant medication: Medications may be necessary later, but immediate safety and airway protection take precedence.
D. Check the client’s oxygen saturation: Monitoring oxygen saturation is important but should follow positioning to ensure airway protection.