A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?

A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.

B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.

C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.

D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.

A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.

B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.

C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.

D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.