The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?
Confirming that the newborn is at least 24 hours old.
Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration.
Assessing the dorsogluteal muscle as the preferred site for injection.
Confirming that the newborn's mother has been infected with the HBV.
The Correct Answer is B
A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B. Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D. Mongolian spots are blue-gray patches on the skin, not associated with head swelling.
Correct Answer is A
Explanation
A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.
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