The nurse is assigned to perform telephone triage for the clinic and receives a call from a young mother whose 6-month-old baby received her third diphtheria–pertussis–tetanus immunization that morning
The mother reports the baby's temperature is 99.8° axillary, the site of injection is "a little red," and the baby is irritable. After checking the standing orders provided by the pediatrician, what teaching would the nurse provide this mother? (Select all that apply.) A) "These are common adverse effects reported after immunizations."
B) "Bring the baby back to the clinic for an examination."
C) "Apply a warm moist compress to the baby's leg."
D) "Aspirin can be given to manage fever symptoms."
E) "Symptoms should subside within 2 to 3 days."
A, C, E
Feedback:
The symptoms reported by this mother are all common adverse effects following immunization that will subside within 2 to 3 days. In the meantime, the mother can make the baby more comfortable by administering a weight appropriate dosage of acetaminophen, applying warm compresses to the injection site, and providing a quiet environment. If the symptoms do not subside within 2 to 3 days, the baby should be seen for follow-up care. Aspirin should not be given due to risk of Reye's syndrome.
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