# An infant scheduled for intramuscular nirsevimab has a platelet count of 18,000/mcL and new petechiae. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522602&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

An infant scheduled for intramuscular nirsevimab has a platelet count of 18,000/mcL and new petechiae. Which action should the nurse take?

## Option

1. Administer the injection without review because monoclonal antibodies cannot cause injection-site bleeding.
2. Hold administration and obtain prompt review of the bleeding risk and the authorized plan. **✔ Correct answer**
3. Massage the injection site forcefully for 10 minutes before giving the medication.
4. Change the intramuscular product to an intravenous bolus without a prescription.

**Correct answer: 2**

## Explanation

Nirsevimab is an intramuscular injection that requires caution in clients with thrombocytopenia or another clinically significant bleeding disorder.

## In-depth explanation

Quick answer
Screen intramuscular biologic administration against severe thrombocytopenia.

Why this is correct
The platelet count and petechiae require an individualized administration decision. Route changes and forceful manipulation are not independent nursing substitutions.

Easy analogy or mental picture
Use a closed medication-safety loop: identify the immune or cytotoxic exposure, connect the new findings, interrupt further harm, stabilize the client, and verify the response over time.

Memory hook
Exposure, immune effect, organ toxicity, infection risk, immediate action, and serial reassessment.

NCLEX decision rule
Choose the action that reduces the most immediate medication-related risk while preserving diagnostic evaluation and authorized treatment.

Why the other choices are wrong
Options that continue the exposure, treat only one symptom, or delay reassessment leave the toxic or infectious process active.References
1DailyMed: BEYFORTUS (nirsevimab)RSV lower respiratory tract disease prevention, serious hypersensitivity, and caution with bleeding disorders

## Clinical scenario

Oncology, transplant, and biologic safety review
Verify the indication, immune status, infection screen, interacting medicines, current organ findings, authorized action, and measurable follow-up.

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