A nurse is caring for a school age child who has pertussis.
Which of the following actions should the nurse take?
Report the diagnosis to the public health department
Place the child in a protected environment for 48hr
Administer the pertussis vaccine
Restrict oral fluids to 500mL per day
The Correct Answer is A
Choice A rationale
Pertussis, also known as whooping cough, is a highly contagious bacterial disease. Health care providers are required to report cases of pertussis to the local health department to help track and control the spread of the disease.
Choice B rationale
Placing the child in a protected environment for 48 hours is not a standard action for a child with pertussis. The child will need to be isolated until they have completed a full course of antibiotics to prevent spreading the infection.
Choice C rationale
Administering the pertussis vaccine is not typically done when a child is already infected. The vaccine is used for prevention, not treatment.
Choice D rationale
Restricting oral fluids to 500 mL per day is not a standard action for a child with pertussis. Adequate hydration is important for children with respiratory infections.
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Correct Answer is D
Explanation
Choice A rationale
Applying a warm pack to the injection site prior to administration is not recommended as it does not effectively reduce pain during immunizations.
Choice B rationale
Asking the parent to leave the room during the injections is not recommended as it may increase the infant’s anxiety and distress.
Choice C rationale
Administering the injections in the deltoid muscle is not recommended for a 2-month-old infant. The recommended site for intramuscular administration of immunizations in children under 18 months of age is the vastus lateralis (anterolateral thigh)3.
Choice D rationale
Administering the injections while the infant is breastfeeding is recommended. Breastfeeding during immunizations has been shown to significantly reduce pain and distress in infants.
Correct Answer is C
Explanation
Choice A rationale
Jacket restraints are typically used to secure a child’s arms during procedures. They are not specifically designed for venipuncture in infants.
Choice Drationale
Elbow restraints are used to secure the child’s elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
Choice Brationale
Mitten restraints are used to prevent the child from scratching or removing tubes. They are not typically used for venipuncture.
Choice Crationale
Mummy restraints are often used for infants during procedures like venipuncture. They allow the child to be wrapped securely while leaving one area exposed for the procedure.
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