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.

Choice A rationale

Covering the insertion site with an opaque dressing is not typically recommended for infants. Transparent dressings are usually preferred because they allow for easy inspection of the site for signs of infection or complications.

Choice B rationale

Using a 24-gauge catheter to start the IV is the correct action. This size is appropriate for a 12-month-old infant and will cause the least amount of discomfort and trauma to the vein.

Choice C rationale

Starting the IV on the infant’s foot is not typically recommended. The hands and arms are usually preferred sites for IV insertion in infants.

Choice D rationale

Changing the IV site every 3 days is not typically necessary unless there are signs of complications such as infection or infiltration. Frequent site changes can cause unnecessary discomfort and trauma to the infant.

The correct answer is D. Have the child flex his head when securing the ties.

Explanation:

When securing tracheostomy ties, flexing the head helps ensure the ties are snug but not too tight. This minimizes the risk of accidental dislodgement while allowing proper airway support.

Why the other options are incorrect:

• A. Use clean technique to change the tracheostomy tube – Incorrect. Sterile technique is required when changing the tracheostomy tube to prevent infection, especially in pediatric clients.

• B. Clean around the stoma with full-strength hydrogen peroxide – Incorrect. Diluted hydrogen peroxide or saline is recommended to avoid tissue irritation. Full-strength hydrogen peroxide can damage delicate skin around the stoma.

• C. Place the child in Trendelenburg position when performing care – Incorrect. The Trendelenburg position (head down, feet up) is not used for tracheostomy care and can increase the risk of aspiration or breathing difficulties.