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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.

Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.

Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.

Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.

A. An adolescent who has sickle cell anemia and slurred speech. B. A toddler who has a partial-thickness burn on his right hand and requires a dressing change. C. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10. D. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.

Correct Answer is A

Explanation

Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.

Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.

Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.

Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.

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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?

Nursing Test Bank

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