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
A. Dinoprostone vaginal inserts (e.g., Cervidil) should be kept frozen until use and do not require thawing or warming before insertion. Allowing the medication to reach room temperature is unnecessary and could compromise its stability and effectiveness.
B. Verifying that informed consent is obtained is essential before administering dinoprostone. The client must understand the purpose, potential risks, and alternatives to labor induction, ensuring ethical and legal standards are met.
C. Semi-Fowler’s positioning may be used during labor but is not a priority immediately after insertion. Positioning is secondary to consent and safety considerations.
D. Instructing the client to avoid urinary elimination is not required for dinoprostone administration and does not impact the safety or effectiveness of labor induction.
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.
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