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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Gestational diabetes mellitus is not a contraindication for a contraction stress test. In fact, clients with gestational diabetes may require additional fetal monitoring due to the increased risk of fetal complications.

B. A previous classical incision, also known as a vertical uterine incision, increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.

C. A previous stillbirth is not a contraindication for a contraction stress test. In fact, it may prompt additional fetal monitoring to assess for potential complications in subsequent pregnancies.

D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test; it is not a contraindication in itself.

A. Epigastric discomfort B. Flank pain C. Temperature 37.7° C (99.8° F) D. Abdominal cramping

Correct Answer is B

Explanation

Rationale:

A. Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.

B. Flank pain is a common manifestation of pyelonephritis, which is an infection of the kidneys.

Clients with pyelonephritis often experience pain in the flank area, which is located between the lower ribs and the pelvis, on one or both sides of the body.

C. A temperature of 37.7°C (99.8°F) may indicate a low-grade fever, which can be present in pyelonephritis due to the body's immune response to infection.

D. Abdominal cramping may occur with various conditions during pregnancy but is not specific to pyelonephritis.

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A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a group of clients. The nurse should recognize that which of the following clients has a contraindication for a contraction stress test?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?

Correct Answer is B

Explanation

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