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?

Administer children's aspirin to help prevent inflammation.

Keep the infant home from daycare for the next two days.

Any level of fever is serious and should be reported right away.

Apply a cool pack to the injection site to reduce discomfort.

Answer and Explanation

The Correct Answer is D

Rationale

A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.

B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.

C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.

D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.

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Correct Answer is B

Explanation

Rationale

A. Fruits can sometimes increase stool acidity or frequency in infants, potentially aggravating diaper rash. However, unless there is a clear association between fruit intake and exacerbation of symptoms, restricting fruits for 24 hours may not directly address the current rash. It's more important to focus on topical care and diaper hygiene.

B. Changing diapers frequently helps keep the skin dry and reduces exposure to irritants like urine and stool. This intervention is crucial as prolonged exposure to moisture can contribute to diaper rash development and exacerbation.

C. Applying a barrier cream or diaper rash ointment can protect the skin from moisture and irritants, providing a protective layer that promotes healing. This intervention helps soothe the skin and prevent further irritation.

D. Using soap and water at every diaper change can be harsh on the delicate skin of infants, especially if the soap is not pH-balanced or contains fragrances. Plain water or a gentle, pH-balanced cleanser is preferable to avoid further irritation.

A. Lay prone for 24 hours after the procedure. B. Report any allergies to shellfish or iodine. C. Report any painful urination, blood in urine, or fever. D. Avoid strenuous activity and sports for at least 2 weeks.

Correct Answer is C

Explanation

Rationale

A. After a cystoscopy, clients typically do not need to lay prone (face down) for an extended period. They are usually allowed to resume normal activities fairly soon after the procedure.

B. This instruction is important because iodine-based contrast agents are commonly used during cystoscopy procedures to enhance visualization of the urinary tract. Clients with allergies to shellfish (due to potential cross-reactivity with iodine) or iodine itself should be identified to avoid allergic reactions. This allows the healthcare team to take appropriate precautions and possibly use alternative agents if needed.

C. This instruction is crucial for monitoring post-procedure complications. Painful urination, blood in urine (hematuria), and fever can indicate infection or other complications following a cystoscopy. Prompt reporting allows for early intervention and treatment if necessary.

D. This instruction is not typically necessary after a cystoscopy. Most clients can resume normal activities, including light exercise, shortly after the procedure. Avoiding strenuous activity for two weeks would be excessive and not aligned with typical post-cystoscopy recovery guidelines.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is B

Explanation

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Correct Answer is C

Explanation

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