A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago.Which finding reported by the parent is the nurse's priority?
Explanation & Rationale
Choice A rationaleTenderness at the injection site is a common local reaction to immunizations, due to tissue irritation or mild inflammation. This is not an urgent concern unless accompanied by systemic symptoms such as fever or significant swelling.Choice B rationaleA mild temperature increase post-vaccination (100.7°F) is a typical immune response to vaccine antigens and does not usually warrant immediate intervention. Fever becomes concerning if it is high-grade (above 102°F) or persistent.Choice C rationaleSwelling around the eyelids and mouth indicates a possible allergic reaction or angioedema, which can be life-threatening if it progresses to airway obstruction. This systemic reaction necessitates immediate evaluation and potential administration of epinephrine.Choice D rationaleReduced feeding may be attributed to mild post-vaccination discomfort or fatigue. While concerning if prolonged, it is not the immediate priority compared to signs of a potential allergic reaction like swelling around the mouth. .