A 6-month-old infant received routine immunizations 8 hours ago. The mother calls the clinic reporting that the infant has a fever of 101.2°F (38.4°C), is fussy, and has redness and swelling at the injection site. What is the most appropriate nursing assessment priority?
1Measure the exact diameter of the injection site redness
2Check for signs of anaphylactic reaction
3Assess the infant's responsiveness and activity level✓ 정답
4Document the fever pattern over the past 8 hours
해설
Assessing overall responsiveness and activity level is the priority to differentiate normal post-vaccination reactions from serious adverse events requiring immediate intervention. Other options focus on specific measurements or less urgent assessments.
Clinical Judgment
This question evaluates prioritization and clinical judgment. The key is to distinguish between a 'normal post-vaccination reaction' and a 'serious adverse reaction'. The reported symptoms (low-grade fever, fussiness, local redness/swelling) are common, expected reactions after a vaccine like DTaP. However, the nurse must always rule out the possibility that these symptoms are early signs of a more serious condition (e.g., encephalitis, sepsis). Therefore, the highest priority assessment is to check the infant's overall neurological status and vital signs. By confirming that the activity level, responsiveness, and consciousness are normal, you can determine if the infant is simply experiencing discomfort rather than a life-threatening situation.
Memory Tip:
Assess Before Measuring! To rule out serious adverse reactions, first assess the infant's overall state (Activity, Responsiveness), then take specific measurements (fever, size of redness).
KR vs US:
In Korea, fever and fussiness after vaccination are also recognized as common reactions, but the NGN/US approach places a stronger emphasis on a systematic and hierarchical assessment for 'Safety'. The 'overall responsiveness' evaluation, along with Vital Signs, is the most basic yet important global assessment tool.
Clinical Practice GuideWhen educating parents after vaccination, please clearly inform them of the following:- Signs that require immediate hospital contact: difficulty breathing, facial/neck swelling, hives, persistent crying (3 hours or more), high fever (e.g., 40°C or higher), convulsions, lethargy or decreased responsiveness.- Expected normal reactions: mild fever, fussiness, local redness/swelling (diameter 2-3 inches or less) within 24-48 hours after vaccination. Explain the possibility of administering an antipyretic (acetaminophen) for mild fever.CautionTrap points in SATA (Select All That Apply) questions! Instructions like "apply a cold compress to the injection site" or "be sure to administer an antipyretic" may not be correct depending on the situation. The nurse's first action should always be Assessment.
DTaP (Diphtheria, Tetanus, acellular Pertussis) — Diphtheria, tetanus, and acellular pertussis combined vaccine. Local reactions (redness, swelling, pain) and systemic reactions (low-grade fever, fussiness) are common.
Anaphylaxis — Severe systemic allergic reaction. Difficulty breathing, angioedema, hives, and low blood pressure progress rapidly. It is a rare but possible emergency situation after vaccination.
Post-vaccination Pyrexia — Fever after vaccination. It is generally mild (around 38.4°C) and resolves within 1-2 days. If high fever persists, other causes should be suspected.
Local Injection Site Reaction — Injection site local reaction. Includes redness (Erythema), swelling (Edema), and tenderness (Tenderness). If the diameter is very large (e.g., 3 inches or more) or accompanied by severe pain, evaluation is needed.
Responsiveness (in infants) — Infant responsiveness. As an indicator of consciousness level, it evaluates lethargy, irritability, unusual crying sounds, and the ability to maintain eye contact. It is a key element in assessing neurological status.