Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder

The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent?

"Do not insert anything in the rectum." Rationale: Children with Wiskott-Aldrich syndrome should not be given rectal suppositories or temperatures since these children are at a high risk for bleeding. Tub baths are not contraindicated. Pacifiers are not contraindicated in Wiskott-Aldrich but should be kept as sanitary as possible to avoid oral infections.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?

"Has she ever had penicillin before?" Rationale: Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond?

"Has your child ever been tested for a peanut allergy?" Rationale: Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?

"Have you noticed any hair loss or redness on your face?" Rationale: Alopecia and the characteristic malar rash (butterfly rash) on the face are common clinical manifestations of SLE. Rhinorrhea, wheezing, and an enlarged spleen are not hallmark manifestations of SLE. Petechiae and purpura are more commonly associated with hematological disorders, not SLE.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?

"Humoral immunity is generally functional at birth." Rationale: Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The nurse is providing education to the parents of a child prescribed oral cyclophosphamide. Which statement by the parent indicates additional teaching is needed?

"I need to give this medication to my child at bedtime." Rationale: Cyclophosphamide is an antineoplastic medication given to clients. It should not be given at bedtime because infrequent voiding could lead to cystitis. It would be administered in the morning. The client should be monitored for infections and signs should be reported to the health care provider. The medication can pass into body fluids; therefore, anyone coming into contact with such fluids, handling contaminated trash or laundry, or changing diapers should wear rubber gloves. Soiled clothing and linens should be washed separately from other laundry. The client needs to drink plenty of fluids and void frequently to avoid cystitis.

The nurse is teaching the parents of a child with a suspected diagnosis of juvenile idiopathic arthritis about the disease. Which statement by the parents demonstrates the need for further teaching?

"If our child does not have a positive rheumatoid factor, our child does not have the disease." Rationale: Unlike adult rheumatoid arthritis, few types of juvenile arthritis actually demonstrate a positive rheumatoid factor. Therapeutic management focuses on inflammation control, pain relief, promotion of remission, and maintenance of mobility. The parents can promote sleep and comfort with a warm bath at bedtime and warm compresses to affected joints or massage. Swimming is a particularly useful exercise to maintain joint mobility without placing pressure on the joints.

The parents of a 5-month-old infant diagnosed with humoral IgA deficiency question the nurse about why the infant was not diagnosed sooner. Which response by the nurse most appropriate?

"Maternal antibodies crossed the placenta and that prevented infections until now." Rationale: IgA deficiency does not have a specific treatment, is usually found when evaluating other illnesses, and is associated with allergies. However, the nurse's most appropriate response to the parents' question about why the infant was not diagnosed sooner is to explain how maternal antibodies prevent manifestation of the deficiency until the infant is approximately 4 months old.

The nurse is providing dietary interventions for a 12-year-old child with a shellfish allergy. Which response by the parent most concerns the nurse?

"My child will likely outgrow this." Rationale: Older children and adolescents with allergic reactions to fish, shellfish, and nuts usually continue to have that concern as a life-long problem. The nurse wants to ensure the parent understands the severity of the allergy and does not expose the child as the child ages. Lobster should be avoided because it is a shellfish. The nurse needs to educate the parent that the child can dine in restaurants as long as questions are asked of meal contents and menus are read carefully. The nurse also needs to explore the parent's feelings; however, client safety is priority.

A pediatric client is newly diagnosed with a stinging-insect allergy. Which advice is most appropriate for the nurse to provide this client's parent?

"Obtain your child a medical alert ID bracelet so the presence of the allergy can be identified easily." Rationale: Stinging-insect allergy can lead to anaphylactic shock. Alerting others to the possibility of an insect sting and allergy is important. To alert others of the allergy, the client should wear a medical alert ID bracelet at all times. A support group may be joined if needed, but is not priority over the client's safety. Genetic testing is not appropriate for allergies. These are tested through allergy testing. It is also not appropriate to recommend testing for foods similar to insect venom.

The mother of a child with a possible food allergy asks the nurse for information about how to test for it. Which response by the nurse would be most appropriate?

"The best way is to eliminate the food from the diet and then look for improvement." Rationale: Food allergies are best identified by eliminating a suspected food from the diet and observing whether symptoms improve. After a time of improvement, the food is reintroduced and if the child is allergic to the food, the symptoms will return. Skin testing with either a patch or intracutaneous injection is ineffective for determining food allergies. Serum antibody levels can be measured but are not specific in helping to determine food allergies.

The nurse is providing instructions to the parents of a child with a severe peanut allergy. Which statement by the parents indicates a need for further teaching about the use of an epinephrine auto-injector?

"The epinephrine auto-injector should be jabbed into the upper arm." Rationale: An epinephrine auto-injector should be jabbed into the outer thigh, as this is a larger muscle, at a 90 degree angle, not into the upper arm. The other statements are correct.

The nurse is providing family education about the administration of cyclosporine A. Which response by the family indicates a need for further teaching?

"The medication is best absorbed with the vitamin C in citrus juices." Rationale: Cyclosporine A should not be taken with grapefruit juice but it may be administered with dairy products. While this medication is being used, the client needs to be monitored for signs of infection and adhere to the schedule for follow-up blood tests to evaluate for complications.

The young girl has been diagnosed with juvenile idiopathic arthritis (JIA) and has been prescribed methotrexate. Which statements by the child's parent indicates that adequate learning has occurred? Select all that apply.

1. "We'll need to bring her back in for some lab tests after she starts methotrexate." 2. "Swimming sounds like a good exercise for her." 3. "A warm bath before bed might help her sleep better." Rationale: The child diagnosed with JIA should not take the oral form of methotrexate with dairy products. The approximate time to benefit from methotrexate is typically 3 to 6 weeks. The child will need blood tests to determine renal and liver function during treatment. Children with juvenile idiopathic arthritis usually find swimming to be useful exercise for them because it helps maintain joint mobility without placing pressure on the joints. Sleep may be promoted by a warm bath at bedtime.

The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level?

1300/mm3 Rationale: The number of CD4 T lymphocytes in the blood helps to determine the effectiveness of antiretroviral therapy. Normal is 1500/mm3 in the infant, so anything below that number may indicate that the therapy is not effective.

The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child should be tested again at what age

4 to 7 weeks Rationale: Virologic testing for HIV-exposed infants should be done with the polymerase chain reaction test at birth, at 4 to 7 weeks, and again at 8 to 16 weeks. Serologic testing is done at approximately 12 months of age to document disappearance of the HIV-1 antibody.

The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child should be tested again at what age?

4 to 7 weeks Rationale: Virologic testing for HIV-exposed infants should be done with the polymerase chain reaction test at birth, at 4 to 7 weeks, and again at 8 to 16 weeks. Serologic testing is done at approximately 12 months of age to document disappearance of the HIV-1 antibody.

The nurse is caring for a child with wheezing, stridor, pallor, vomiting, and a rash. When the nurse asks the child about pain, the child groans in response. An intravenous line is present. Which action by the nurse is priority?

Administer epinephrine intramuscularly. Rationale: Epinephrine is the standard treatment for anaphylaxis, regardless of the cause. Signs and symptoms of anaphylaxis include wheezing, pallor, vomiting, and a rash. Stridor and decreased consciousness may indicate the child has progressed to airway obstruction and shock. Diphenhydramine and albuterol will not reverse anaphylactic shock. Assessing oxygen saturation is not the first action the nurse should take when anaphylaxis is suspected.

Which nursing intervention is priority when caring for a child with HIV?

Administer prescribed medications. Rationale: Although assisting with activities, assessing pain, and reviewing CD4 counts are all important, the priority when caring for a child with HIV is to administer prescribed medications. Prescribed medications prevent progressive deterioration of the immune system and provide prophylaxis against opportunistic infections.

A school-aged child, who is allergic to bee stings, states, "I think I was stung by a bee outside." Which intervention by the school nurse is most appropriate?

Assess the client for signs of anaphylactic shock Rationale: First, the nurse will assess the client for signs of anaphylactic shock and then administer epinephrine if warranted. Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing. If there were no signs of anaphylactic shock, the nurse would determine if the child was actually stung. The nurse would apply ice to promote vasoconstriction once the client was stable.

The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first?

Discontinue the infusion. Rationale: Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority.

The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?

Elimination Diet Rationale: An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.

Which immunoglobin occurs most frequently in plasma and is the major immunoglobulin synthesized during secondary response?

IgG Rationale: IgG is the most frequent antibody in plasma and is the major immunoglobin to be synthesized during the secondary response. IgG represents about 75% of all serum antibodies. Most of the newborn's IgG is transferred via the placenta to the fetus. The infant develops passive immunity to antigens in which the mother has developed antibodies. The infant begins to manufacture IgG after about 6 months of age. IgG reaches 50% of its adult level at 1 year of age and full adult level at age 7 years. IgD is only found in about 1% of plasma. Its function is to signal for B cells to be activated. IgA protects the mucous membranes against the invasion of microbes. IgM is the first antibody to respond to infection.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are caring for a pediatric client with an immune disorder receiving a stem cell transplant. Which action by the UAP will cause the RN to intervene?

The UAP takes a rectal temperature on the client. Rationale: Precautions must be taken to protect the client from infection. The RN would intervene if the UAP takes a rectal temperature because this increases the client's risk for infection. The client should not receive rectal suppositories as well. The RN would ensure meticulous oral care is provided and encourage appropriate and adequate nutrition. Delivering a meal tray, wearing a mask when entering the room, and assisting the client to ambulate in the room are all appropriate actions by the UAP.

The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take?

The nurse should encourage the child to talk with his parents about his medications. Rationale: Generally, children older than 6 years of age will eventually need to have their diagnosis disclosed to them in an age-appropriate manner. They begin to ask questions and often seem to sense that something is going on other than what they've been told so far. Encouraging discussion with the parents is the best first step.

The nurse receives a call from a parent whose toddler received a prescription for amoxicillin one teaspoon every 8 hours. The child has received 2 doses and the parent is noticing unusual symptoms. Which symptoms may indicate a severe penicillin allergy? Select all that apply.

Wheezing, Urticaria, Serum Sickness Rationale: A child with a severe penicillin allergy might very likely show symptoms such as wheezing, urticaria, and serum sickness. True drug allergies most commonly affect the dermatologic, immunologic, hemolytic, and respiratory systems.

A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. What would the nurse expect to administer?

Zidovudine Rationale: Zidovudine is a nucleoside reverse transcriptase inhibitor. Nevirapine and efavirenz are classified as nonnucleoside reverse transcriptase inhibitors. Ritonavir is a protease inhibitor.

The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first?

a child reporting coughing, itching, and anxiety Rationale: The first child the nurse will see is the child showing signs and symptoms of an allergic reaction, which includes coughing, itching, and anxiety. Children with IgA deficiency are likely to experience rhinitis. Lethargy is a common symptom of HIV. A child with a vesicular rash with yellow crusts most likely has atopic dermatitis (eczema).

The nurse is educating a child with a peanut allergy about the signs and symptoms of an anaphylactic reaction. The nurse realizes additional teaching is needed when the child identifies which sign/symptom?

constipation Rationale: Signs and symptoms of an anaphylactic allergic reaction include nausea, anxiety, and itchy mouth. Diarrhea, rather than constipation, is a sign of an allergic reaction.

The most accurate screening test for the presence of HIV antigen in young children is:

polymerase chain reaction (PCR). Rationale: PCR tests directly for the HIV antigen. ELISA and the Western blot test detect the presence of HIV antibodies. The CD4 count is used as a measure of disease status and progression.

The nurse is caring for a child with juvenile idiopathic arthritis (JIA). There is involvement of five or more small joints and it is affecting the body symmetrically. This tells the nurse that the child:

has polyarticular JIA. Rationale: Polyarticular JIA is defined by the involvement of five or more joints, frequently the small joints, and affects the body symmetrically. Pauciarticular JIA is defined by the involvement of four or fewer joints. Systemic JIA presents with fever and rash in addition to join involvement at the time of diagnosis. The child with JIA is not at greater risk for anaphylaxis.

The nurse is explaining to a parent some of the basic aspects of the immune system and its functions. She informs them that B cells, also known as _________ cells, will attack __________ antigens.

humoral; bacterial Rationale: B cells are also called humoral cells and typically attack bacterial organisms. Another term for T cells is killer cells, and they most commonly attack viral organisms.

A child with systemic lupus erythematosus is receiving hydroxychloroquine sulfate. Which instruction would the nurse emphasize when teaching the child and parents about this drug?

importance of yearly eye examinations Rationale: When hydroxychloroquine is given, the child should have a fundoscopic eye exam and visual field testing every year. Corticosteroids need to be tapered gradually over time. Cyclosporine A should not be taken with grapefruit juice. Nonsteroidal anti-inflammatory agents should be given with food to decrease gastrointestinal upset.

The nurse is caring for a child with HIV. The doctor will most likely order which test to monitor the child's progress?

lymphocyte immunophenotyping T-cell quantification Rationale: Lymphocyte immunophenotyping T-cell quantification is for ongoing monitoring of progressive depletion of CD4 T lymphocytes in HIV disease. The nurse would expect the physician to order a complement assay (C3 and C4) for ongoing monitoring of systemic lupus erythematosus. IgG subclasses measure the levels of the four subclasses of IgG and are used to determine immunodeficiencies. Immunoglobulin electrophoresis is ordered for immunodeficiency and autoimmune disorders, not to monitor systemic lupus erythematosus.

The nurse is caring for a child presenting with eye inflammation, knee pain, poor appetite, and poor weight gain. The nurse is aware that this is which type of juvenile idiopathic arthritis?

pauciarticular (oligoarticular) Rationale: Pauciarticular (oligoarticular) arthritis symptoms include involvement of four or fewer joints; quite often the knee is involved. Eye inflammation, malaise, poor appetite, and poor weight gain may also be present. Polyarticular involves five or more joints, frequently involves small joints, and often affects the body symmetrically. Systemic JIA includes joint involvement, fever, and rash. Rheumatic arthritis typically involves small joints.

A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread? Select all that apply.

1. Exposure to blood and body fluids via sexual contact. 2. Sharing contaminated needles, Transfusion of contaminated blood 3. Perinatally from mother to fetus 4. Through breastfeeding. Rationale: HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding. It cannot be contracted by using the same bathroom. It must be direct contact.

The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?

erythrocyte sedimentation rate (ESR) Rationale: The erythrocyte sedimentation rate (ESR) is an indicator of inflammation; it would likely be elevated during an exacerbation of arthritis. Immunoglobulin electrophoresis determines the level of individual immunoglobulins; it would not be elevated in an autoimmune disease. Lymphocyte immunophenotyping T-cell quantification measures T-cells; this would be used to monitor immunosuppressive disorders. The radioallergosorbent test measures minute quantities of IgE in the blood; it is used for asthma and food allergy testing.

The nurse is providing education regarding 2030 Health Goals to reduce the incidence of acquired immunodeficiency syndrome (AIDS) within the community. Which goal will the nurse choose as a primary prevention strategy?

Provide education to sexually active females about proper condom usage. Rationale: Primary prevention strategies focus on preventing a disease before it occurs, which includes condom usage to prevent being exposed to AIDS. Screening for the presence of AIDS is a secondary prevention strategy because it does not prevent an individual from contracting AIDS, but would allow for early identification. Improving air quality and reducing allergens are goals to prevent allergies.

The nurse is preparing to administer IVIG to a child who has not received the medication before. What medication should the nurse expect to administer prior to the infusion?

diphenhydramine Rationale: Premedication with diphenhydramine or acetaminophen may be indicated in children who have never received IVIG, have not had an infusion in more than 8 weeks, have had a recent bacterial infection, have a history of serious infusion-related adverse reactions, or are diagnosed with agammaglobulinemia or hypogammaglobulinemia. Aspirin, ibuprofen, and prednisone would not routinely be administered prior to IVIG.

The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply.

1. Acute otitis media, one episode every 3-4 weeks over the past year 2. Recurrent deep abscess of the thigh, 3. Oral candidiasis (thrush), persistent over the past 6-7 months. Rationale: Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral candidiasis (thrush) or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs.

The nurse is preparing an informational brochure about risk factors for immune disorders. Which disease process can indicate a potential underlying immunologic disorder? Select all that apply.

1. Persistent oral thrush 2. Chronic cough 3. Extensive eczema Rationale: Occasional rhinorrhea is common and does not indicate an immune disorder. Illness with high fever is a sign of acute illness, rather than a chronic underlying disorder such as immune dysfunction.

The nurse is preparing to administer the child's dose of intravenous immune globulin (IVIG). Which actions should the nurse take? Select all that apply.

1. Take baseline vital signs and monitor the vital signs during the infusion. 2. Prepare to give acetaminophen to the child. 3. Prepare to give diphenhydramine to the child. Rationale: IVIG should be given only intravenously and should not be given as an intramuscular injection. IVIG cannot be mixed with other medications. The nurse should closely monitor the child's vital signs during the infusion of the IVIG. The child may require an antipyretic and/or an antihistamine during infusion to help with fever and chills.

The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond?

"Does your child get a whipped cream or foam topping on their favorite drink?" Rationale: Albumin, globulin, ovalbumin should be avoided if allergic to eggs. Some foam toppings for drinks contain these substances and would cause an allergic reaction to the person allergic to eggs. This would be important information to ascertain from the family as they would likely not be aware of this.

The nurse is working with a pregnant client who is HIV positive and has been prescribed oral zidovudine. Which statement by the nurse explains the primary rationale for taking this medication?

"It is to help prevent transmission of the disease to your infant." Rationale: A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine, which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir or indinavir, in conjunction with a nucleoside reverse transcriptase inhibitor (NRTI). Kaposi sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability. This medication has no affect on the fetus's growth and development.

A client is being admitted to the medical unit for exacerbation of symptoms of systemic lupus erythematosus (SLE). When assessing the client, the nurse notices a butterfly-shaped rash across the client's cheeks and bridge of the nose. Which action by the nurse is most appropriate?

Document the finding in the client's medical record. Rationale: A butterfly-shaped rash over the cheeks and bridge of the nose is a common occurrence with SLE. The nurse would document the findings and continue with the admission process. There is no need to notify the health care provider at this time. The nurse would not apply any medication without a prescription. Corticosteroid creams or pills are sometimes prescribed for clients with SLE. Clients with SLE may experience sensitivity to light; however, this is not related to the rash. The nurse may ask about light sensitivity but not because of the presence of this rash.

NextGen: A school nurse is called to the school cafeteria after a 13-year-old child is reported to have sudden difficulty breathing. The child has a history of asthma and allergies to peanuts. The focused nursing assessment reveals difficulty breathing, inspiratory and expiratory wheezing, swelling of lips, and a rash on the face. The child reports feeling nauseated, having chest tightness, and feeling faint. Complete the following sentence(s) by choosing from the lists of options. The nurse should first address the child's ______________ then _____________.

1st: Wheezing 2nd: Swelling of Lips Rationale: The nurse addresses the airway first; wheezing indicates constriction of the airways. The nurse next addresses the child's swollen lips (angioedema) to ensure there is no additional swelling in the mouth that may occlude the airway. Once the nurse addresses the child's airway, breathing, and circulation, the nurse can address the child's nausea. Because the rash does not interfere with the child's airway, breathing, or circulation, and it will resolve once the allergic episode resolves; this can be addressed later. The child's chest tightness is most likely due to the bronchial constriction. Once the airway constriction resolves, the chest tightness should resolve. The child feeling faint is most likely due to the bronchial constriction reducing airflow. Once the airway constriction resolves, the child should not feel faint.

The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated?

Instruct the child be brought to the emergency department promptly. Rationale: Myasthenia gravis is an autoimmune disorder that is characterized by weakness and fatigue. There is no cure. The disease may be aggravated by stress, exposure to extreme temperatures, and infections, resulting in a myasthenic crisis. Myasthenic crisis is a medical emergency with symptoms including sudden respiratory distress, dysphagia, dysarthria, ptosis, diplopia, tachycardia, anxiety, and rapidly increasing weakness. The symptoms reported are consistent with a crisis and prompt care is indicated. Waiting 24 hours to have the child seen by the physician is not appropriate. Questions about changes in routine and medication compliance may be asked but the first priority is to have the child seen.

The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of greatest concern?

elevated blood pressure Rationale: Renal complications may result from lupus. This may be accompanied by hypertension, making monitoring of blood pressure of the highest importance.

The nurse is planning to administer IVIG to a child for the first time. What actions related to this therapy are indicated? Select all that apply.

1. After mixing, roll the vial of medication. 2. Store the vial in the fridge until use. 3. Promote hydration prior to administration. 4. Medicate with acetaminophen prior to administration. Rationale: IVIG must be reconstituted. After the diluent is added to the powder, gently roll the vial between your hands to mix. Shaking will damage the medication. Reconstituted IVIG may be refrigerated overnight but should be brought to room temperature prior to infusion. Premedication with acetaminophen may be indicated in children who have never received IVIG. The child should be well hydrated prior to the administration. Adverse reactions should be monitored for within 15 minutes of the initiation of the infusion.