A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Use a 20-gauge needle to administer the vaccine.
Choose a 3/8-inch needle to administer the vaccine.
Administer the vaccine into the dorsal gluteal muscle.
Administer 0.5 mL of the vaccine.
The Correct Answer is B
A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.
Correct Answer is C
Explanation
A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.
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