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
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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
Blood pressure 80/50 mm Hg: Indication of Potential Worsening Condition - A decrease in blood pressure may indicate hypovolemic shock due to ongoing or worsening postpartum hemorrhage.
Cloudy urine: Indication of Potential Worsening Condition - Cloudy urine may indicate a urinary tract infection or another complication, which can worsen the client's condition.
Moderate lochia rubra: Indication of Potential Worsening Condition - Continued moderate lochia rubra suggests ongoing or worsening postpartum hemorrhage.
Fundus firm to palpation: Indication of Potential Improvement - A firm fundus suggests effective uterine contraction and control of bleeding, indicating potential improvement.
Fundus at level of umbilicus: Indication of Potential Worsening Condition - The fundus being at the level of the umbilicus suggests uterine atony or continued bleeding, which is a worsening condition.
Correct Answer is C
Explanation
Rationale:
A. Instructing the client about an autopsy is not the immediate priority and may not be appropriate at this sensitive time.
B. Informing the client about the law regarding naming the fetus is not a priority and may add unnecessary stress to the situation.
C. Providing photos of the fetus is the most appropriate action since it minimzes the trauma to the mother while providing closures.
D. Limiting the amount of time the fetus is in the client's room is not appropriate as when the mother needs more time with the fetus, she hsould be allowed to provide for closure
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