A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

A. Use a 1.8 mm (0.5 in) needle:

Rationale: Needle length is typically not measured in millimeters for intramuscular injections. The length of the needle for intramuscular injections in preschoolers is usually longer, ranging from 16 to 25 mm (5/8 to 1 inch), depending on factors such as the child's size and the thickness of adipose tissue at the injection site.

B. Use a 20-gauge needle:

Rationale: While the gauge of the needle is important for controlling the flow rate of the medication, the size of the gauge alone does not determine the appropriateness of the needle for administering a vaccine into the deltoid muscle of a preschooler. The gauge of the needle commonly used for intramuscular injections in children is typically between 22 and 25 gauge.

C. Insert the needle at a 15-degree angle:

Rationale: When administering an intramuscular injection into the deltoid muscle, the needle should be inserted at a 90-degree angle (perpendicular to the skin) for children and adults. Using a 15-degree angle would result in a subcutaneous injection rather than reaching the muscle tissue.

D. Insert the needle just below the acromion process:

This is the correct action. When administering a vaccine into the deltoid muscle of a preschooler, the nurse should insert the needle just below the acromion process. This landmark helps ensure accurate placement of the needle into the deltoid muscle, which is the recommended site for intramuscular injections in preschool-age children.

A. Expressive affect: Individuals with autism spectrum disorder (ASD) often have difficulty expressing their emotions in a typical manner. They may display a restricted range of facial expressions or have difficulty conveying emotions through facial expressions and gestures. However, "expressive affect" typically refers to the appropriate display of emotions, which may not be characteristic of ASD.

B. Ambivalence: Ambivalence refers to conflicting feelings or attitudes about a situation or person. While individuals with ASD may experience a range of emotions, including ambivalence, it is not a specific characteristic associated with the disorder. Ambivalence is a common human experience and may occur in individuals with or without ASD.

C. Echolalia: Echolalia is a common communication characteristic observed in individuals with ASD. It involves the repetition or echoing of words or phrases spoken by others. This behavior may occur immediately after hearing the words or phrases (immediate echolalia) or may be delayed. Echolalia can serve various functions, including communication, self-regulation, or expression of anxiety.

D. Associative looseness: Associative looseness is a thought disorder characterized by a lack of logical connection between thoughts and ideas. It is typically associated with conditions such as schizophrenia rather than ASD. Individuals with ASD may exhibit difficulties with social communication, including challenges in maintaining conversations or understanding social cues, but this is different from the disorganized thinking observed in associative looseness.