A child was seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red
Which of the following instructions would the nurse provide to the mother? 1. Call the physician.
2. Apply warm compresses on the site.
3. Return to the health care clinic immediately.
4. Apply cold compresses for 24 hours following the injection.
4
Rationale: For painful or red injection sites, the nurse should instruct the mother to apply cold compresses for the first 24 hours and then to use warm or cold compresses as long as needed. "Call the physician," "apply warm compresses on the site," and "return to the health care clinic immediately" are incorrect. It is not necessary for the mother to bring the child to the clinic im-mediately, and it is not necessary for the mother to contact the physician.
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