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?
Redness at the injection site.
Temperature 37.7°C (99.9°F).
Hives on the child's neck.
Prolonged crying.
The Correct Answer is C
Choice C rationale
Hives on the child's neck is the priority finding because it can indicate an allergic reaction, which may progress to anaphylaxis. Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention. Hives are often the first sign of an allergic reaction and can quickly escalate to airway obstruction, difficulty breathing, and cardiovascular collapse. Early identification and treatment of an allergic reaction can prevent these severe complications. The nurse should be prepared to administer emergency medications, such as epinephrine, and provide respiratory support if needed.
Choice A rationale
Redness at the injection site is a common and expected local reaction following immunization. It typically resolves on its own without intervention. While it may cause some discomfort, it does not pose an immediate threat to the child's health and is not a priority over signs of a potential allergic reaction.
Choice B rationale
A temperature of 37.7°C (99.9°F) is a mild fever and a common response to immunizations as the body mounts an immune response. It is not usually cause for concern and can be managed with antipyretics if necessary. This mild fever does not indicate an urgent condition compared to the signs of an allergic reaction.
Choice D rationale
Prolonged crying can be a sign of discomfort or pain following an immunization but is not necessarily indicative of a severe reaction. It is important to assess the child's overall condition and provide comfort measures. However, it does not take precedence over signs of an allergic reaction, which require immediate attention.
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Correct Answer is D
Explanation
Choice A rationale
Adding medication to a child's formula is not recommended as the child may refuse the entire feeding, making it difficult to ensure the full dose is taken.
Choice B rationale
Placing small bits of ice on a child's tongue is not an effective or safe method for administering medication. Ice can be a choking hazard and may not aid in the process.
Choice C rationale
Positioning a child on their back during medication administration increases the risk of aspiration. It's safer to keep them slightly upright.
Choice D rationale
Placing the medication along the inside of the child's cheek (buccal administration) ensures the medication is swallowed slowly and safely, reducing the risk of choking and aspiration.
Correct Answer is C
Explanation
Choice A rationale
Massaging the injection site after administering a vaccine is generally not recommended as it may cause irritation or introduce bacteria to the site, increasing the risk of infection. Additionally, massaging the area does not improve the absorption or efficacy of the vaccine. Vaccines are designed to be absorbed effectively by the body without the need for additional manipulation. Healthcare professionals are trained to administer vaccines using techniques that minimize discomfort and ensure proper delivery of the vaccine into the muscle tissue.
Choice B rationale
Aspiration, or pulling back on the syringe plunger after inserting the needle but before injecting the vaccine, is not recommended when administering vaccines. Studies have shown that aspiration is unnecessary and may increase the risk of injury, pain, and prolonged injection time. The practice of aspiration is based on the outdated concern of inadvertently injecting the vaccine into a blood vessel. However, research indicates that the risk of this occurring is extremely low when proper injection techniques are used. The focus should be on delivering the vaccine quickly and efficiently to minimize discomfort.
Choice C rationale
Ensuring that the guardian has signed a consent form for immunization is an essential step in the vaccination process. Obtaining informed consent means that the guardian is aware of the potential benefits and risks associated with the vaccine and agrees to proceed with the vaccination. This practice is crucial for maintaining trust between healthcare providers and patients, respecting the rights of individuals to make informed healthcare decisions, and adhering to legal and ethical standards in medical practice. Proper documentation of consent is also important for record-keeping and future reference.
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