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 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.

A. Use a lancet to puncture the inner aspect of the newborn's heel. B. Leave the newborn's heel open to the air after the puncture. C. Apply an antiseptic to the newborn's heel after collecting the specimen. D. Warm the newborn's heel for 5 to 10 min before the puncture.

Correct Answer is A

Explanation

A) Correct - Newborn screening typically involves a heel stick using a lancet to collect a few drops of blood from the inner aspect of the newborn's heel.
B) Incorrect- Leaving the newborn's heel open to the air after the puncture is not necessary; a small bandage is typically applied.
C) Incorrect- An antiseptic is not typically applied after collecting the specimen, as it could interfere with the accuracy of the screening tests.
D) Incorrect- Warming the newborn's heel is not a standard step before collecting a specimen for newborn screening.

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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 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

A nurse is preparing to collect a specimen for newborn screening. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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