a nurse is preparing to administer a measles mumps and rubella mmr vaccine to a 15 month old child which of the following findings is a contraindicati
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Nursing Elites

ATI RN

ATI Pediatrics Proctored Exam 2023

1. A healthcare professional is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. Which of the following findings is a contraindication to the administration of this vaccine?

Correct answer: B

Rationale: Taking antibiotics is a contraindication to receiving the MMR vaccine because antibiotics can potentially interfere with the effectiveness of the vaccine. It is essential to avoid administering the MMR vaccine while the child is on antibiotics to ensure the vaccine provides the intended protection.

2. A child is being cared for by a nurse and has rheumatic fever. Which of the following actions should the nurse plan to take?

Correct answer: D

Rationale: Rheumatic fever can lead to cardiac complications, such as dysrhythmias. Therefore, it is essential for the nurse to monitor the child's heart rate closely for any signs of dysrhythmias. This will help in early identification and prompt management of potential cardiac issues associated with rheumatic fever. Choices A, B, and C are not the priority actions in this scenario. While aspirin may be used in the treatment of rheumatic fever, monitoring for cardiac complications takes precedence. Encouraging fluid intake and providing warm compresses are helpful interventions but do not directly address the cardiac risks associated with rheumatic fever.

3. Which statement is not part of the developmental care approach?

Correct answer: B

Rationale: The developmental care approach emphasizes creating an environment that supports the infant's developmental needs, including family-centered care, a healing environment, and promoting protected sleep. Payment scale considerations are not a component of developmental care.

4. What is the probable cause recognized by the nurse when a 5-year-old boy is admitted to the hospital with acute glomerulonephritis?

Correct answer: D

Rationale: Acute glomerulonephritis typically develops 1 to 3 weeks after a streptococcal infection, such as a sore throat, which triggers an allergic-type response that affects the glomeruli's function. This immune response leads to inflammation and damage to the glomeruli, resulting in acute glomerulonephritis.

5. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?

Correct answer: D

Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.

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