the clinic nurse is reviewing the immunization guidelines for hepatitis b which are true of the guidelines for this vaccine
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Nursing Elites

ATI RN

Nursing Care of Children ATI

1. The clinic nurse is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for this vaccine?

Correct answer: B

Rationale: Hepatitis B vaccination should start at birth, and any child or adolescent not vaccinated should complete the series. Adolescents should receive three doses if they were not previously vaccinated.

2. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

3. The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby’s formula faster. What should the nurse recommend?

Correct answer: B

Rationale: Heating formula in a plastic bottle in the microwave can cause uneven heating and release harmful chemicals from the plastic.

4. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

Correct answer: D

Rationale: Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as muscle cramps, tetany, or seizures. Other symptoms like nausea, vomiting, and weakness are less specific and can be related to various conditions.

5. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

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