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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Glycogen.Preterm newborns have limited stores of glycogen, which is a substance made from glucose that is stored in the liver and muscle cells to be used later for energy.When blood glucose levels are low, the hormone glucagon signals the cells to convert glycogen back into glucose and release it into the bloodstream.However, preterm newborns have a reduced ability to produce glucagon and to use gluconeogenesis, which is the process of making new glucose from other sources.Therefore, they are at risk of hypoglycemia, which is a condition where blood glucose levels are too low to support normal brain function.
Choice B is wrong because glucose is the sugar that travels through the blood to fuel the cells, not a substance that is stored for later use.
Choice C is wrong because insulin is a hormone that helps cells absorb glucose from the blood, not a substance that is stored for later use.
Choice D is wrong because glucagon is a hormone that triggers the release of glucose from the liver and muscle cells, not a substance that is stored for later use.
Correct Answer is C
Explanation
The correct answer is choice C. A temperature of 36°C (96.8°F) is below the normal range for a newborn, which is 36.5°C to 37.5°C (97.7°F to 99.5°F).
A low temperature can indicate hypothermia, infection, or hypoglycemia, and should be reported to the provider.
Choice A is wrong because a heart rate of 140/min is within the normal range for a newborn, which is 120 to 160/min.
Choice B is wrong because a respiratory rate of 50/min is within the normal range for a newborn, which is 30 to 60/min.
Choice D is wrong because a blood pressure of 60/40 mm Hg is within the normal range for a newborn, which is 50 to 75/30 to 45 mm Hg.
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