A nurse is assisting with the care of a newborn whose mother has hepatitis B. Which of the following actions should the nurse plan to take when administering the hepatitis B vaccine?

Insert the needle at a 45° angle

Obtain parental consent

Give the first dose at 24 hr after birth.

Administer the medication into the dorsal gluteal muscle

Answer and Explanation

The Correct Answer is C

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B)   Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C)   Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D)   Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

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Correct Answer is ["B","C","E"]

Explanation

A) Incorrect- Dry, cracked skin is not typically associated with a newborn born at 43 weeks of gestation. It's more common in post-term babies.
B) Correct - Hypotonia (low muscle tone) is a possible finding in post-term newborns due to the aging placenta and potential decrease in amniotic fluid.
C) Correct - Excessive lanugo (fine, downy hair) is more likely to be present in post-term babies as they have less vernix to protect their skin.
D) Incorrect- Absent vernix might be more characteristic of a post-term newborn, but its presence or absence varies widely.
E) Correct - Long, hard nails can be a characteristic of post-term babies, as they have had more time for nail growth in the womb.

A. Monitor for infection. B. Position the client supine. C. Obtain consent for a cesarean birth. D. Prepare for a forceps delivery.

Correct Answer is A

Explanation

A) Correct - Monitoring for infection is an appropriate nursing intervention for a client whose membranes have ruptured, as there is an increased risk of infection after the amniotic sac has ruptured for an extended period.
B) Incorrect- Positioning the client supine is not generally recommended for a client in labor, especially if the client's membranes have ruptured.
C) Incorrect- Obtaining consent for a cesarean birth is not indicated solely based on the information provided.
D) Incorrect- Preparing for a forceps delivery is not indicated solely based on the information provided.

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A nurse is assisting with the care of a newborn whose mother has hepatitis B. Which of the following actions should the nurse plan to take when administering the hepatitis B vaccine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who is 1 hr old and was born at 43 weeks of gestation. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assisting in the care of a client who is in labor and whose membranes ruptured 6 hr ago. Which of the following is an appropriate nursing intervention for this client?

Correct Answer is A

Explanation

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