Reference no: EM133708947

Question

Maria's caregiver called the nurse to report that Maria is hurting again. Maria indicated to the nurse the pain is in their "stomach and back." The nurse medicated Maria with morphine 1.8 mg IV, which they can have every 2 hours, for pain of 6 on the FACES pain scale. The nurse informed Maria's caregiver that the provider has prescribed for the child to have a unit of packed red blood cells be transfused. The caregiver informed the nurse that Maria has never had a transfusion before but would give consent for it. The nurse has verified the provider's prescription, transfusion consent form signed, child's identification, blood type, expiration, and compatibility with another nurse. The nurse has initiated a unit of packed red blood cells for Maria. The child's vital signs are blood pressure 96/58 mm Hg, temperature 38° C (100° F), heart rate 98/min, respiration 24/min. An hour into the transfusion, the nurse observes urticaria on the upper trunk and upper extremities and neck. The child is talkative, no adventitious breath sounds or reports of pain. Which of the following actions should the nurse take? (Select all that apply.) Stop the transfusion immediately. Discontinue the 0.9% sodium chloride. Administer