Author Question: The nurse administers immunizations to the toddler, and instructs the mother to: 1. Wait in the ... (Read 37 times)

casperchen82 · **on:** Jul 22, 2018

The nurse administers immunizations to the toddler, and instructs the mother to:

1. Wait in the waiting area for 30 minutes before leaving.
2. Apply ice to the injection site if discomfort occurs.
3. Limit activity of the extremity where the immunization was injected.
4. Observe for allergic reaction over the next 4-6 hours.

Question 2

The nurse anticipates what assessment finding when examining the infant with hydrocephalus?

1. Sclera seen above the iris, or setting sun appearance
2. Flexing of the extremities even when sleeping or resting
3. Edema of the eyelids and the lower arms and legs
4. Excess crying and irritability when picked up

AngeliqueG · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale: The nurse should have the clients remain in the facility for 20-30 minutes after administering an immunization in case of a severe anaphylactic reaction to the medication. Other instructions to the mother might include application of warm compresses to an injection site that becomes red or edematous, maintaining activity of the extremity to improve absorption of the medication, and observing for signs of an allergic reaction within 24 hours of immunization.

Answer to Question 2

1
Rationale: Infants with hydrocephalus will often be found to have setting sun appearance to the eyes. Flexing of extremities is a normal finding in term neonates.