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. 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.
Correct Answer is A
Explanation
Rationale:
A. When teaching parents about the Plastibell circumcision technique, it's important to explain that a yellow exudate (sometimes referred to as granulation tissue) will typically form at the surgical site within 24 hours after the procedure. This is a normal part of the healing process and should not be a cause for concern.
B. The end of the penis will likely get red, then develop a yellow discharge, and finally scab over, “like a skinned knee.” This is the normal healing process and will progress over the 7-14 days that the Plastibell Ring stays on. The correct size Plastibell Ring is secured with a string and the excess skin trimmed. The skin that overlaps the ring will turn dark “like the umbilical cord” before the ring falls off at 7-14 days.
C. The Plastibell is typically left in place for several days, not removed 4 hours after the procedure.
D. Ensuring the newborn's diaper is snug may help keep the Plastibell in place, but it is not the most crucial aspect of care related to the circumcision technique.
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