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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. The mother should always smoke in another room. B. The effects of secondhand smoke on infants are less significant than for adults. C. No relationship exists between smoking and the time of feedings. D. Smoking has little-to-no effect on milk production.

Correct Answer is A

Explanation

A. Encouraging the mother to smoke in another room helps reduce the exposure of the newborn to secondhand smoke.
B. The effects of secondhand smoke on infants are significant and can increase the risk of respiratory infections, sudden infant death syndrome (SIDS), and other health issues.
C. There is a clear relationship between smoking and breastfeeding, and smoking during breastfeeding should be minimized.
D. Smoking can affect milk production and composition, and it is advisable for breastfeeding mothers to quit smoking.

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The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?

A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide?