Final answer:
The initial action a nurse should take when a child complains of back pain and itching during a transfusion is to discontinue the transfusion immediately. This response is critical in preventing further exposure to a potentially incompatible blood product and managing a transfusion reaction.
Step-by-step explanation:
When a child receiving a transfusion complains of back pain and itching, the nurse's initial action would be to discontinue the transfusion. These symptoms can be indicative of a transfusion reaction, which is a potentially serious and immediate threat to the patient's health. It is critical to stop the transfusion to prevent further exposure to the potentially incompatible blood product. After halting the transfusion, the nurse should maintain IV access with saline, monitor the patient's vital signs, notify the physician, and follow the institution's protocol for transfusion reactions, which typically includes sending the remaining blood product and a fresh blood sample back to the lab for analysis.
Antihistamine administration may be necessary, but only after the transfusion is stopped and under the direction of a physician. Increasing the transfusion rate or simply documenting the findings without immediate intervention are not appropriate responses as they could place the patient at higher risk. The prompt cessation of the transfusion is the priority to ensure the safety of the patient. Thus, the correct option in this scenario is b) Discontinue the transfusion.