A nurse is planning to administer immunizations to a 2-month -old infant. Which of the following actions should the nurse take to decrease the infant pain.
apply a warm pack to the injection site prior to administration.
Ask the parent to leave the room during the injections.
Administer the injections in the deltoid muscle.
Administer the injections while the infant is breastfeeding?
The Correct Answer is D
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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Children with autism spectrum disorder often thrive on routines and predictability. Varying daily routines can be distressing and may lead to increased anxiety.
Choice B rationale
Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.
Choice C rationale
This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.
Choice D rationale
Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.
Correct Answer is A
Explanation
The correct answer is A. Antibiotics initiated 24 hr ago.
Explanation:
Children with bacterial meningitis require droplet precautions to prevent the spread of infection. These precautions can typically be discontinued after 24 hours of effective antibiotic therapy, as the risk of transmission significantly decreases.
Why the other options are incorrect:
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B. Negative cerebrospinal fluid (CSF) culture – While a negative CSF culture confirms the absence of bacteria, cultures may take several days to process. Droplet precautions are usually lifted based on treatment duration, not pending lab results.
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C. Absent nuchal rigidity – Nuchal rigidity (stiff neck) is a symptom of meningitis, but its resolution does not determine infectious risk.
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D. Temperature below 37.4°C (99.4°F) – Fever reduction is a sign of improvement but does not indicate that the infection is no longer transmissible.
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