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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.

B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.

C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.

D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.

A. "I will give my child a chocolate malt for a snack." B. "I should provide my child with rice pudding for dessert." C. "I should make my child's sandwiches using rye bread." D. "I will feed my child a barley-based breakfast cereal."

Correct Answer is B

Explanation

A. Chocolate malt typically contains malted barley, which contains gluten. This would not be appropriate for a child with celiac disease, as gluten can trigger an immune response and cause damage to the small intestine.

B. Rice is a gluten-free grain, making rice pudding a safe food choice for children with celiac disease. The parent demonstrates understanding of appropriate gluten-free foods.

C. Rye bread contains gluten, which is harmful to individuals with celiac disease. Rye is not a suitable option for this child.

D. Barley contains gluten and should be avoided in children with celiac disease. Barley-based breakfast cereals would not be safe for the child.

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A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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