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.

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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.

A. Apply gentle pressure to stop bleeding B. Change his diaper more frequently C. Document this as a normal finding D. Notify his physician

Correct Answer is C

Explanation

The correct answer is choice C. Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.

Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.

Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.

Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection.Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.

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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 caring for a preterm newborn who has hypoglycemia due to inadequate gluconeogenesis. The nurse should understand that this condition occurs because preterm newborns have limited stores of which of the following substances?

Correct Answer is A

Explanation

The nurse is caring for a newborn who was circumcised using a Gomco clamp 12 hours ago and notes that there is a small amount of blood on his diaper where his penis rests against it. The most appropriate nursing action would be to:

Correct Answer is C

Explanation

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?

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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?