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학습 자료 둘러보기 →Mild systemic reactions like fever (102°F/38.9°C), vomiting, and lethargy are common within 12-24 hours of routine immunizations and reflect an active immune response.
The priority nursing action is parental reassurance and providing comfort measures, including administering an ordered antipyretic like acetaminophen. This manages symptoms while avoiding unnecessary emergency visits.
Immediate escalation is required for signs of a serious adverse event, such as a fever ≥105°F (40.5°C), inconsolable crying for ≥3 hours, seizure, or signs of an allergic reaction (difficulty breathing, urticaria).
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