A nurse is administering the Haemophilus influenzae type B vaccine (Hib) to a 6-month-old infant. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
• Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.

Rationale for Incorrect Choices:

• Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
• Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
• Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
• Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.

A. Monitor vital signs every 8 hr: Vital signs should be monitored more frequently in a child with diabetic ketoacidosis (DKA) than every 8 hours. Monitoring every 1-2 hours is typically recommended in order to detect any signs of deterioration or complications early.
B. Initiate continuous cardiac monitoring: Cardiac monitoring is important in the management of DKA because the condition can lead to electrolyte imbalances (especially hypokalemia), which can affect heart rhythm and potentially cause arrhythmias.
C. Administer subcutaneous insulin 30 min before meals: In SKA, insulin should not be administered subcutaneously until the child’s condition is stabilized, as intravenous (IV) insulin is typically used initially to correct acidosis and hyperglycemia in DKA.
D. Implement fluid restrictions: Fluid restrictions are not appropriate in DKA. Aggressive fluid resuscitation is necessary to correct dehydration and restore proper electrolyte balance. Fluid restrictions could worsen dehydration and acidosis.