A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.
Which instruction should the nurse provide the parent about care of the infant after the injections?

Choice A rationale

Determining the amount of weight the patient has lost since increasing activity is relevant to the patient’s overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

Choice B rationale

Inquiring about the patient’s exercise schedule is a reasonable action. It allows the nurse to gather information about the patient’s exercise routine and assess whether it might be contributing to the sleep difficulties. For instance, exercising too close to bedtime can interfere with sleep. Therefore, understanding the timing and intensity of the patient’s exercise can provide valuable insights into potential adjustments that could improve sleep quality.

Choice C rationale

Informing the patient that lifestyle changes often take several weeks to be effective is a general statement that might not address the specific concerns of the patient. While it’s true that lifestyle changes, including exercise, can take time to show results, this does not provide a targeted solution to the patient’s reported difficulty in falling asleep.

Choice D rationale

Encouraging the patient to exercise daily to reduce bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the patient’s sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

Choice A rationale

The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.

Choice B rationale

While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore