Before administering the first series of immunizations to a 2-month-old infant, the nurse tells the mother that reactions may occur. What are the characteristics of these reactions? a. Local or systemic and usually mildb. Often serious, possibly requiring hospitalizationc. Sometimes causing ulceration at the injection sited. May be responsible for permanent neurological damage

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1. Before administering the first series of immunizations to a 2-month-old infant, the nurse tells the mother that reactions may occur. What are the characteristics of these reactions?

a. Local or systemic and usually mild

b. Often serious, possibly requiring hospitalization

c. Sometimes causing ulceration at the injection site

d. May be responsible for permanent neurological damage

A!

Mild reactions consist of redness and induration at the injection site, slight fever, and irritability. Serious reactions are not common. Induration at the injection site may occur, but not ulceration. Permanent brain damage is not likely after an immunization.
C!

Liquid oral iron supplements may stain the teeth; brushing the teeth after administration may limit the discoloration. There should be no change in the color of the urine. Yellowing of the skin is a sign of jaundice; it is not a side effect of an iron supplement. The stools will become black-green; clay-colored stools are a sign of biliary obstruction.
A!

The nurse should teach the mother how to formula feed, because cultural beliefs are deeply ingrained and it is unlikely at this time that the nurse will change the client's mind. Explaining to the mother that these beliefs are wrong is a judgmental response that does not take into consideration the client's beliefs or feelings. It is not therapeutic to contradict the client, especially when the alternative to breastfeeding will not harm the mother or infant. Providing the mother with books indicating that the milk does not sour is a judgmental response that does not recognize the client's beliefs or feelings. This is not therapeutic. Antianxiety medications are contraindicated in breastfeeding women.
B!

Primary prevention is focused on health promotion and illness prevention. Tertiary prevention is focused on rehabilitation and the reduction of residual effects. Secondary prevention is focused on early detection and treatment. No type of prevention is specifically known as therapeutic; however, all types of prevention should be therapeutic.
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