A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?
Massage the injection site for 15 seconds after administration.
Administer the vaccine into the dorsogluteal muscle.
Ensure the guardian signed an informed consent form for the immunization.
Aspirate for the presence of blood return prior to administering the vaccine.
The Correct Answer is C
A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.
B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.
C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.
D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.
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Related Questions
Correct Answer is D
Explanation
A. Performing a head tilt and chin lift is typically used in resuscitation for unresponsive infants, not for choking. It is not effective in clearing an obstructed airway in a conscious or choking infant.
B. Placing the infant in a side-lying position and performing abdominal thrusts is incorrect. Abdominal thrusts are not recommended for infants. Back blows and chest thrusts are used to clear an infant's airway.
C. Suctioning with a bulb syringe is appropriate for clearing mucus or secretions from the airway, but it would not be effective for a choking infant. The first action should be to attempt back blows or chest thrusts.
D. Delivering back blows with the infant face down over the rescuer’s arm is the correct initial action. The infant should be supported by the arm, and back blows should be administered to try to expel the obstruction from the airway. This is the first step in the infant choking protocol.
Correct Answer is A
Explanation
A. Tachycardia is a common finding in infants with heart failure. The body compensates for decreased cardiac output by increasing heart rate to maintain adequate perfusion to vital organs.
B. Blood pressure may not necessarily increase in heart failure. In fact, in severe cases, it can be low due to poor cardiac output.
C. Increased urinary output is not a typical manifestation of heart failure. In fact, heart failure often results in decreased renal perfusion, leading to decreased urine output.
D. Bounding peripheral pulses are usually seen in conditions like fever or hyperdynamic circulatory states, not in heart failure. In heart failure, peripheral pulses may be weak due to reduced cardiac output.
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