A mother brings her child to the clinic for his last diphtheria-pertussis-tetanus (DPT) immunization. The mother tells the nurse that the child developed a red rash after the previous diphtheria-pertussis-tetanus (DPT) immunization
What does the best action by the nurse include?
1. Administer only a pertussis-tetanus immunization.
2. Withhold this immunization and contact the physician.
3. Tell the mother to give the child acetaminophen (Tylenol) if another rash develops.
4. Administer diphenhydramine (Benadryl) prior to the diphtheria-pertussis-tetanus (DPT) immunization.
Correct Answer: 2
Rationale 1: There is no such immunization as pertussis-tetanus.
Rationale 2: This red rash is unexpected and could indicate a potential adverse reaction to the vaccine such as anaphylaxis, so the nurse should withhold the immunization and contact the physician.
Rationale 3: The nurse should not tell the mother to administer acetaminophen (Tylenol); this will not prevent anaphylaxis.
Rationale 4: The nurse cannot administer diphenhydramine (Benadryl) without a physician's order.
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