A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?
Instruct the mother to delay breastfeeding for 1 week.
Initiate airborne precautions.
Wait at least 24 hr before bathing the newborn.
Administer hepatitis B immune globulin IM to the newborn.
The Correct Answer is D
A. Breastfeeding is not contraindicated in mothers with hepatitis B if the newborn receives appropriate prophylaxis.
B. Airborne precautions are not necessary; hepatitis B is transmitted through blood and body fluids, not airborne droplets.
C. Bathing the newborn does not affect hepatitis B transmission risk and does not need to be delayed.
D. Administering hepatitis B immune globulin (HBIG) IM to the newborn within 12 hours of birth, along with the first dose of the hepatitis B vaccine, is essential to prevent vertical transmission of hepatitis B virus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.
Correct Answer is B
Explanation
A. While bilirubin levels are important, the immediate concern for a large-for-gestational-age (LGA) newborn is hypoglycemia.
B. LGA newborns are at increased risk for hypoglycemia, so monitoring blood glucose levels is essential.
C. Arterial blood gases are not routinely indicated unless respiratory distress is present.
D. WBC count is not specifically related to LGA status.
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