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 score of 4 would indicate severe distress, but the baby in this scenario shows signs of responsiveness and activity.
B. A score of 6 suggests moderate adaptation to extrauterine life, considering some components of the APGAR are within the normal range.
C. A score of 10 is perfect, but the noted symptoms suggest some difficulties.
D. A score of 9 would be high and not consistent with the observed signs of distress.
Correct Answer is D
Explanation
A. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.
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