A nurse is assessing a child who has received the first 50 mL of a blood transfusion. Which of the following findings indicates that the child might be experiencing an air embolism?

Choice A rationale An air embolism occurs when air enters the bloodstream, travels to the heart, and becomes trapped in the pulmonary circulation. This blockage obstructs blood flow to the lungs, leading to symptoms like sharp chest pain, sudden shortness of breath, and signs of respiratory distress. Sharp pain is a key indicator of this event. Choice B rationale Severe itching of the hands is a common symptom of a mild allergic reaction to a blood transfusion. It is caused by the release of histamine from mast cells and basophils in response to an immune reaction to plasma proteins or other components in the donor blood. This is not indicative of an air embolism. Choice C rationale Distended neck veins are a sign of circulatory overload, where the heart is unable to handle the increased fluid volume from the transfusion. This causes blood to back up in the venous system, increasing central venous pressure. This is a different type of transfusion reaction and not a symptom of an air embolism. Choice D rationale A decreased temperature, or hypothermia, is an uncommon finding during a blood transfusion. It may occur if a large volume of cold blood is administered too rapidly, which is especially a risk in pediatric patients. An air embolism typically presents with signs of cardiovascular and respiratory compromise, not a drop in temperature.