A nurse is preparing to administer hepatitis B vaccine to a newborn whose mother is hepatitis B surface antigen negative (HBsAg-).

Which of the following actions should the nurse take?

Obtain informed consent from the mother before giving the vaccine

Give the vaccine intramuscularly in the anterolateral thigh

Administer hepatitis B immune globulin (HBIG) along with the vaccine

Delay giving the vaccine until after breastfeeding is established

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Give the vaccine intramuscularly in the anterolateral thigh.

This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.

It has a large muscle mass and minimal risk of injury to nerves or blood vessels.

Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.

Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.

Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.

Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is choice A. Bulging fontanelle.

A bulging fontanelle is a sign of increased intracranial pressure, which can be caused by intracranial hemorrhage.

Late-onset VKDB is a condition that occurs in infants who have low levels of vitamin K, which is essential for blood clotting.Most cases of late-onset VKDB present with intracranial hemorrhage.

Choice B. Sunken eyes is wrong because it is a sign of dehydration, not intracranial hemorrhage.

Choice C. Mottled skin is wrong because it is a sign of poor circulation or shock, not intracranial hemorrhage.

Choice D. Flaring nostrils is wrong because it is a sign of respiratory distress, not intracranial hemorrhage.

Normal ranges for vitamin K plasma concentrations are 0.2 to 3.2 ng/mL for adults and 0.15 to 1.5 ng/mL for infants.

A. Administer fresh frozen plasma B. Administer packed red blood cells C. Administer intravenous immunoglobulin D. Administer recombinant erythropoietin

Correct Answer is A

Explanation

The correct answer is choice A. Administer fresh frozen plasma.This is because fresh frozen plasma contains clotting factors that can help stop the bleeding caused by vitamin K deficiency.Vitamin K is needed for the synthesis of clotting factors in the liver, but newborns have low levels of vitamin K and may develop vitamin K deficiency bleeding (VKDB) if they do not receive prophylaxis at birth.VKDB can manifest as bleeding in various sites, such as the skin, mucous membranes, umbilicus, gastrointestinal tract, or central nervous system.

Choice B is wrong because packed red blood cells do not contain clotting factors and will not correct the underlying deficiency of vitamin K.

Choice C is wrong because intravenous immunoglobulin is used to treat immune-mediated thrombocytopenia, not vitamin K deficiency.

Choice D is wrong because recombinant erythropoietin is used to stimulate red blood cell production in anemia, not to treat bleeding disorders.

Early-onset VKDB occurs within 24 hours of birth and is associated with maternal use of drugs that interfere with vitamin K metabolism, such as anticoagulants, anticonvulsants, or antituberculosis drugs.

These drugs induce the enzymes that break down vitamin K in the fetal liver

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to administer hepatitis B vaccine to a newborn whose mother is hepatitis B surface antigen negative (HBsAg-). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who has late-onset VKDB due to exclusive breastfeeding and inadequate oral vitamin K supplementation. Which of the following findings should indicate a possible intracranial hemorrhage to the nurse?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has early-onset VKDB due to maternal use of anticoagulants during pregnancy. Which of the following interventions should the nurse anticipate for this newborn?

Correct Answer is A

Explanation

A nurse is performing an initial assessment of a newborn who was delivered vaginally at term with no complications. Which of the following findings should alert the nurse to a potential problem?

A nurse is caring for a newborn who has received erythromycin eye ointment as prophylaxis for ophthalmia neonatorum. What should the nurse monitor for as a potential adverse reaction to this medication?

A nurse is administering erythromycin eye ointment to a newborn who has a history of allergic reaction to penicillin. What should the nurse do before applying the ointment?

A nurse is reviewing laboratory results for a newborn who received vitamin K injection at birth. Which of the following coagulation factors should be activated by vitamin K?

A nurse is caring for a client who has chronic hepatitis B infection and is taking lamivudine (Epivir). The nurse should monitor the client for which of the following adverse effects?

The nurse is teaching parents how to care for their son’s circumcision site after discharge from hospital using petroleum jelly and gauze dressing method. Which statement by parents indicates that they need further instruction?

A nurse is educating a new mother about umbilical cord care and how to prevent omphalitis, sepsis, and tetanus. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is assessing a newborn’s vital signs at 1 hour of age. Which of the following findings should the nurse report to the provider?

A nurse is preparing to administer hepatitis B vaccine to a newborn whose mother is hepatitis B surface antigen negative (HBsAg-).

Which of the following actions should the nurse take?