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

Rationale:
A) Incorrect - A blood pressure of 120/70 mm Hg is within the normal range and is not a contraindication for the transdermal contraceptive patch.
B) Incorrect - Peptic ulcer disease is not a contraindication for the transdermal contraceptive patch.
C) Correct - A weight of 98 kg (216 lb) is considered a contraindication for the transdermal contraceptive patch due to potential reduced efficacy in women with a body mass index (BMI) over 30. This method might be less effective for individuals with higher body weights.
D) Incorrect - A history of spontaneous abortion is not a contraindication for the transdermal contraceptive patch.

A. A client who has a reddened area on their right calf B. A client who reports painful uterine contractions during breastfeeding C. A client who has a urinary output of 125 mL in 4 hr D. A client who reports changing their perineal pad every 2 hr

Correct Answer is C

Explanation

A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who is requesting a prescription for a transdermal contraceptive patch. The nurse should recognize which of the following client findings is a contraindication for this method of contraception.

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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