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.

Answer and Explanation

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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Correct Answer is C

Explanation

A) Incorrect- The water heater temperature should be set to 49.4°C (120°F) or below to prevent scalding. The given temperature is slightly too high.
B) Incorrect- Soft bumper pads in cribs can pose a suffocation risk and are not recommended.
C) Correct - Washing the newborn's face with a warm, soapy washcloth is a safe way to cleanse the baby's face. Harsh chemicals or strong soaps should be avoided.
D) Incorrect- Pillows should not be placed under a newborn's head during naps to reduce the risk of suffocation. The baby's sleep environment should be free of soft bedding.

A. Respiratory rate 32/min B. Temperature 38.3° C (101°F) C. Apical pulse 66/min D. Blood pressure 156/80 mm Hg

Correct Answer is A

Explanation

A) Correct - An elevated respiratory rate could indicate postpartum hemorrhage as the body compensates for decreased oxygen-carrying capacity due to blood loss.
B) Incorrect- An elevated temperature might indicate infection, but it is not a specific indication of postpartum hemorrhage.
C) Incorrect- A normal apical pulse rate does not specifically indicate or rule out postpartum hemorrhage.
D) Incorrect- An elevated blood pressure might occur for various reasons postpartum, including anxiety or pain, but it is not a specific indication of postpartum hemorrhage.

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A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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