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's pain?
Ask the parent to leave the room during the injections.
Administer the injections while the infant is breastfeeding.
Apply a warm pack to the injection site prior to administration.
Administer the injections in the deltoid muscle.
The Correct Answer is B
Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.
Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.
Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.
Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The concrete operational phase typically begins around age 7 and is characterized by the development of logical thought about concrete events. This phase is not typical for preschoolers, who are usually between the ages of 3 and 5.
Choice B reason: The formal operational phase usually starts at age 11 or older. It involves abstract thinking and the ability to systematically plan for the future, which is beyond the cognitive abilities of a preschooler.
Choice C reason: The preoperational phase occurs from ages 2 to 7. During this stage, children begin to engage in symbolic play and learn to manipulate symbols, but they do not yet understand concrete logic.
Choice D reason: The sensorimotor phase is from birth to about age 2. During this stage, infants learn about the world through their senses and actions, such as looking and touching. Preschoolers have typically moved beyond this phase.
Correct Answer is A
Explanation
Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.
Choice B reason: A BUN level of 6 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.
Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.
Choice D reason: A BUN level of 12 mg/dL is slightly elevated but may not be immediately concerning. It should be evaluated in conjunction with other laboratory values and clinical findings.
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