Difficulty: Medium
Average Score: 70%
Simulated
A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Correct answer
D
Rationale
Hives may signal anaphylaxis, a priority due to its life-threatening potential. Redness, mild fever, and crying are common but less urgent post-immunization reactions.