Difficulty: Medium
Average Score: 85%
Simulated
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Correct answer
C
Rationale
Hives on the neck may indicate an allergic reaction, potentially anaphylactic, requiring immediate action. Crying, redness, and mild fever are common and less urgent.