A nurse is planning to administer immunizations to a 2-month -old infant. Which of the following actions should the nurse take to decrease the infant pain.
apply a warm pack to the injection site prior to administration.
Ask the parent to leave the room during the injections.
Administer the injections in the deltoid muscle.
Administer the injections while the infant is breastfeeding?
The Correct Answer is D
Choice A rationale
Applying a warm pack to the injection site prior to administration is not recommended as it does not effectively reduce pain during immunizations.
Choice B rationale
Asking the parent to leave the room during the injections is not recommended as it may increase the infant’s anxiety and distress.
Choice C rationale
Administering the injections in the deltoid muscle is not recommended for a 2-month-old infant. The recommended site for intramuscular administration of immunizations in children under 18 months of age is the vastus lateralis (anterolateral thigh)3.
Choice D rationale
Administering the injections while the infant is breastfeeding is recommended. Breastfeeding during immunizations has been shown to significantly reduce pain and distress in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Performing the examination once every other month is not the recommended frequency. It is generally recommended that males perform a testicular self-examination monthly.
Choice B rationale
Notifying your provider if your testes are firm and egg-shaped may not be necessary, as this is generally considered a normal characteristic of testes. However, any changes in size, shape, or consistency should be reported.
Choice C rationale
Waiting a month after feeling a hard lump is not recommended. If a hard lump is detected during a self-
examination, it should be reported to a healthcare provider immediately, as it could be a sign of testicular cancer.
Choice D rationale
Performing the examination following a warm shower is recommended. The warmth relaxes the scrotum, making it easier to examine the testicles.
Correct Answer is C
Explanation
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
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