The nurse is reviewing the nurse’s notes and flow chart to identify trends.
Which notations require immediate follow-up?

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.