A nurse is reviewing the transcutaneous bilirubin measurement of a newborn who is 48 hours old and has physiologic jaundice.

The measurement is 16 mg/dL.

Which of the following actions should the nurse take?

These are normal inflammatory responses to the vaccine.

The tetanus vaccine protects people from the bacteria that cause tetanus, a serious disease that causes muscle stiffness and spasms.

The vaccine stimulates the body’s immune system to produce antibodies against the bacteria.Sometimes, this immune response can cause mild symptoms such as pain, redness, swelling, fever, headache, or tiredness.

These are not signs of an infection or an allergic reaction, but rather the body’s way of building immunity.

Choice A is wrong because an allergic reaction to the vaccine would cause more severe symptoms such as hives, swelling of the face or throat, difficulty breathing, or shock.

These symptoms would usually occur within minutes or hours of getting the vaccine and require immediate medical attention.

Choice C is wrong because these are not signs of an active infection with tetanus.

Tetanus is a rare but potentially fatal disease that causes muscle spasms and paralysis.

It is caused by bacteria that enter the body through wounds or cuts.The symptoms of tetanus usually appear several days or weeks after exposure and include lockjaw, stiffness of the neck and abdomen, difficulty swallowing, fever, sweating, and seizures.

The tetanus vaccine prevents the disease by creating immunity before exposure.

Choice D is wrong because these are not adverse effects of preservatives in the vaccine.

Preservatives are substances that prevent contamination and spoilage of vaccines.The most common preservative used in tetanus vaccines is thimerosal, a mercury-based compound that has been proven to be safe and effective.

There is no evidence that thimerosal causes autism or any other health problems.

Some people may have a sensitivity to thimerosal or other ingredients in the vaccine, but this is very rare and would cause an allergic reaction as described in choice A.

Dextrose 10% in water.This is because parenteral nutrition (PN) is a mixture of nutrients that is given through a central venous catheter (CVC) that goes directly to the heart.PN contains high concentrations of nutrition and calories, and if the PN bag is empty, it needs to be replaced with a solution that has a similar osmolarity to prevent complications such as hypoglycemia (low blood sugar) or phlebitis (inflammation of the vein).Dextrose 10% in water has an osmolarity of about 500 mOsm/L, which is close to the osmolarity of PN solutions.

Choice A is wrong because 0.9% sodium chloride has an osmolarity of about 300 mOsm/L, which is lower than PN solutions and can cause fluid overload and electrolyte imbalance.

Choice B is wrong because lactated Ringer’s has an osmolarity of about 275 mOsm/L, which is also lower than PN solutions and can cause similar problems as 0.9% sodium chloride.

Choice D is wrong because dextrose 5% in water has an osmolarity of about 250 mOsm/L, which is much lower than PN solutions and can cause rapid drop in blood sugar and vein irritation.