A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Use a 21-gauge needle for the injection.
Insert the needle at a 45° angle for injection.
Administer the injection into the vastus lateralis muscle.
Vigorously massage the site following the injection.
The Correct Answer is C
Rationale:
A. Using a 21-gauge needle may be too large for a newborn, increasing the risk of discomfort and tissue damage.
B. Inserting the needle at a 45° angle may not be appropriate for intramuscular injections in newborns. The preferred angle is typically 90°.
C. Administering the injection into the vastus lateralis muscle is the recommended site for hepatitis B vaccination in newborns. This site is located on the anterior lateral aspect of the thigh and provides good muscle mass for injection.
D. Vigorously massaging the site following the injection is not recommended as it may increase discomfort and tissue trauma. Instead, gentle pressure can be applied to the site to help reduce discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Vaginal candidiasis would not typically contraindicate the use of a suppository for constipation.
B. A third-degree perineal laceration involves injury to the anal sphincter and rectal mucosa, making the use of a suppository contraindicated due to the risk of exacerbating the injury and causing further discomfort.
C. Abdominal distention may indicate constipation, which could be a reason for using a suppository, rather than a contraindication.
D. Afterpains, or uterine cramping after childbirth, would not typically contraindicate the use of a suppository for constipation.
Correct Answer is C
Explanation
Rationale:
A. Provide the newborn with 15 ml glucose water after each feeding: This action is not directly related to phototherapy for jaundice treatment.
B. Turn the newborn every 4 hours: While turning the newborn is important for preventing pressure ulcers, it is not specifically related to phototherapy.
C. Close the newborn's eyes before applying eyepatches:
Correct answer. It is important to protect the newborn's eyes from phototherapy light by using eye patches or covering their eyes with soft material to prevent damage to the retina.
D. Apply hydrating lotion to the newborn's skin prior to treatment: Hydrating lotion is not typically applied before phototherapy, as it may interfere with the effectiveness of the treatment or cause skin irritation.
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