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 B

Explanation

Choice A reason:

Placing a folded blanket to pad the back of the infant's head is not recommended, as it can interfere with the proper fit of the car seat harness and potentially be a safety hazard.

Choice B reason:

This statement is correct. Infant car seats should be positioned at a 30-degree angle to provide optimal support for the infant's head and neck, as well as to prevent airway obstruction.

Choice C reason:

While car seats with a four-point harness do exist, a standard infant car seat typically has a five- point harness system.

Choice D reason:

The retainer clip should be positioned at the level of the infant's armpits to ensure that the harness is snug and secure.

A. Subcutaneously into the vastus lateralis B. Intramuscularly using the Z-track method C. Subcutaneously into the deltoid D. Intramuscularly using a 20-gauge needle

Correct Answer is B

Explanation

Choice A reason:

Administering iron dextran subcutaneously into the vastus lateralis is not the recommended route for this medication. It is typically administered intramuscularly.

Choice B reason:

Correct. The preferred method for administering iron dextran is intramuscularly using the Z-track method. This technique helps prevent leakage of the medication into the subcutaneous tissue.

Choice C reason:

Administering iron dextran subcutaneously into the deltoid is not the preferred route for this medication. It is typically administered intramuscularly.

Choice D reason:

While a 20-gauge needle may be appropriate for intramuscular injections, the Z-track method is the preferred technique for administering iron dextran intramuscularly. The gauge of the needle may vary depending on the specific circumstances and patient characteristics.

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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?

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