A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Temperature 37.7° C (99.9° F)

Redness at the injection site

Prolonged crying

Hives on the child's neck

Answer and Explanation

The Correct Answer is D

Choice A reason:

A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.

Choice B reason:

Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.

Choice C reason:

Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.

Choice D reason:

Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.

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Correct Answer is C

Explanation

Choice A reason:

While it's important to reassure the child, stating that it's not their fault is correct, the statement in choice C is a stronger affirmation of the inappropriateness of the situation.

Choice B reason:

This statement may inadvertently place blame on the child, which is not appropriate in this situation.

Choice C reason:

This statement communicates empathy and acknowledges that the child should not have experienced maltreatment.

Choice D reason:

While it's important to maintain the child's trust, the priority is to ensure the child's safety and report any suspected maltreatment to the appropriate authorities.

A. Give the child a pacifier that has been dipped in an oral sucrose solution during the procedure. B. Apply a eutectic mixture of local anesthetics cream to the intended puncture site 1 hr before the procedure. C. Instruct the parent how to perform kangaroo care during the procedure. D. Administer aspirin to the child 1 hr before the procedure.

Correct Answer is A

Explanation

Choice A reason:

Using a pacifier dipped in an oral sucrose solution can help provide comfort and alleviate pain during the procedure, making it a suitable option for blood specimen collection in preschoolers.

Choice B reason:

Applying a eutectic mixture of local anesthetics cream may not be the most appropriate option for blood specimen collection in preschoolers, as it may not provide sufficient pain relief for the procedure.

Choice C reason:

Kangaroo care involves skin-to-skin contact between an infant and a parent, which is beneficial for bonding and comfort but may not be directly applicable to a blood specimen collection procedure.

Choice D reason:

Placing the infant in a prone position for sleeping is not related to blood specimen collection and may not be appropriate immediately postoperatively.

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A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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