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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A child’s weight being in the 45th percentile is within the normal range and is not in itself an indicator of physical abuse.
Choice B rationale
Bruising around the wrists can be a potential indicator of physical abuse. Unexplained bruises, particularly in unusual locations or in specific patterns, can be a sign of physical abuse.
Choice C rationale
Abrasions on the knees are common in children due to normal play and activity and are not typically an indicator of physical abuse.
Choice D rationale
Missing front deciduous teeth in a 7-year-old student is not typically an indicator of physical abuse. It is normal for children to begin losing their deciduous (baby) teeth around this age.
Correct Answer is A
Explanation
Choice A rationale
A preschool-age child being curious about what happened to the sibling’s body is an age-appropriate response to death. At this age, children often view death as temporary or reversible, and they may be curious about the physical realities of death.
Choice B rationale
A preschool-age child feeling responsible for the sibling’s death is not an age-appropriate response to death. While children at this age may sometimes believe their thoughts or actions can influence events, it’s not typical for them to feel personally responsible for a death.
Choice C rationale
A preschool-age child being able to give a logical explanation for the sibling’s death is not an age-appropriate response to death. Preschoolers typically have a limited understanding of the causes and permanence of death.
Choice D rationale
A preschool-age child viewing the sibling’s death as permanent is not an age-appropriate response to death. Most children in this age group do not understand that death is permanent.
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