Health Promotion and Maintenance
82. Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply.
Health Promotion and Maintenance
82. Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply.
. Current cold symptoms (e.g., runny nose, cough).
. History of recent blood transfusion.
. Currently taking corticosteroids.
. Mild diarrhea without symptoms of dehydration.
. Family history of penicillin allergy.
. Positive for HIV.
Test-Taking Tip
Mild to moderate illness is not a contraindication for immunization. The child must be significantly immunocompromised or at risk for diminished immune response for the nurse to withhold immunization.
Content Area: Child Health, Infectious Disease; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Immunizations
Health Promotion and Maintenance
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Answer 1 is incorrect because the common cold is not a contraindication for receiving immunizations; it does not cause a decreased response to vaccines. Young children have many mild cold viruses each year; avoiding immunizations during these times may cause a child to miss many immunizations. Answer 2 is correct because antibodies present in the transfused blood can inhibit the immune response to the immunization. Answer 3 is correct because corticosteroids can suppress the immune response, limiting the effectiveness of immunization. Answer 4 is incorrect because mild diarrheal illness is not a contraindication to immunization. However, moderate to severe diarrhea is a contraindication since the child's immune response may not be sufficient if immunizations are administered. Answer 5 is incorrect because penicillin allergy is not a contraindication to immunization. Allergy to streptomycin is a contraindication for IPV (inactivated polio vaccine), and allergy to neomycin is a contraindication for MMR (measles, mumps, and rubella), IPV, and varicella. Answer 6 is correct because a child with HIV should not receive immunizations that contain live viruses (e.g., varicella), as these may lead to infection.