A nurse is administering the Haemophilus influenzae type B vaccine (Hib) to a 6-month-old infant. Which of the following actions should the nurse take?
Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle
Administer the vaccine subcutaneously in the abdomen using a 16-mm in needle
Administer the vaccine subcutaneously in the upper arm using a 13-mm (-n) needle.
Administer the vaccine in the dorsogluteal muscle using a 51 mm (2-in) needle
The Correct Answer is A
A. Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle: For infants, the vastus lateralis muscle in the thigh is the preferred site for intramuscular (IM) vaccinations, including the Hib vaccine. A 25-mm (1-in) needle is an appropriate length for this muscle in a 6-month-old infant.
B. Administer the vaccine subcutaneously in the abdomen using a 16-mm (5/8-in) needle: The Hib vaccine is not administered subcutaneously. It is an intramuscular injection, and the abdomen is not the recommended site for this vaccine.
C. Administer the vaccine subcutaneously in the upper arm using a 13-mm (1/2-in) needle: The Hib vaccine is administered intramuscularly, not subcutaneously. The upper arm is used for intramuscular injections in older children. A 13-mm needle is too short for an intramuscular injection in the vastus lateralis.
D. Administer the vaccine in the dorsogluteal muscle using a 51-mm (2-in) needle: The dorsogluteal muscle is not recommended for infants due to the risk of damaging the sciatic nerve. A 2-inch needle is too long for this area in an infant.
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Naxlex Comprehensive Predictor Exams
Related Questions
Complete the following sentence by using the lists of options.
The nurse should recommend to
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.
Correct Answer is "{\"xRanges\":[324.828125,364.828125],\"yRanges\":[66,106]}"
Explanation
A. This area is over the cheek and facial soft tissue. Cephalohematomas do not occur here, as they are confined to the skull bones under the periosteum.
B. This point is positioned over the parietal area of the skull, the typical site for cephalohematoma formation due to birth trauma. Cephalohematoma is a subperiosteal hemorrhage confined to the surface of the skull, most commonly over the parietal bone, and does not cross suture lines. Palpating this area helps determine whether the lesion has resolved or calcified.
C. This region is the lower abdominal or pelvic area, which is not relevant for assessing cranial birth trauma like cephalohematoma.