A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
Use a 21-gauge needle for the injection.
Insert the needle at a 45° angle for injection.
Administer the injection into the vastus lateralis muscle.
Vigorously massage the site following the injection.
The Correct Answer is C
Rationale:
A. Using a 21-gauge needle may be too large for a newborn, increasing the risk of discomfort and tissue damage.
B. Inserting the needle at a 45° angle may not be appropriate for intramuscular injections in newborns. The preferred angle is typically 90°.
C. Administering the injection into the vastus lateralis muscle is the recommended site for hepatitis B vaccination in newborns. This site is located on the anterior lateral aspect of the thigh and provides good muscle mass for injection.
D. Vigorously massaging the site following the injection is not recommended as it may increase discomfort and tissue trauma. Instead, gentle pressure can be applied to the site to help reduce discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Determining the client's apical pulse rate is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
B. Asking the client if they are taking the medication as prescribed is a direct way to evaluate medication adherence. Open communication with the client can provide valuable insight into their medication-taking behavior.
C. Assessing the client's kidney function is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
D. Checking the client's serum medication level can provide information about medication concentration but may not necessarily indicate adherence, as the level could be within the therapeutic range even if the client is not taking the medication as prescribed.
Correct Answer is A
Explanation
A. Positioning the car seat at a 45-degree angle helps to ensure that the baby's airway remains open and reduces the risk of slumping, which can lead to suffocation. This positioning is essential for newborns who may have limited head and neck control.
B. A car seat challenge test is typically performed for preterm infants or those with specific health concerns, not for all newborns. Newborns delivered at 38 weeks generally do not require this test unless there are other complications.
C. Car seat safety guidelines recommend that infants remain in a rear-facing position until at least 2 years of age, not just until they turn 1 year old. This statement does not demonstrate an understanding of current safety recommendations.
D. While sleep sacks can help keep a baby warm, they should not be used in a way that compromises the harness system of the car seat. It’s crucial to ensure that the baby is snugly secured in the car seat without any additional bulky clothing or blankets that could interfere with the safety harness.
In summary, the correct understanding is that the car seat should be positioned at a 45-degree angle for optimal safety.
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