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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.
B. Flank pain is a common manifestation of pyelonephritis, which is an infection of the kidneys.
Clients with pyelonephritis often experience pain in the flank area, which is located between the lower ribs and the pelvis, on one or both sides of the body.
C. A temperature of 37.7°C (99.8°F) may indicate a low-grade fever, which can be present in pyelonephritis due to the body's immune response to infection.
D. Abdominal cramping may occur with various conditions during pregnancy but is not specific to pyelonephritis.
Correct Answer is C
Explanation
Rationale:
A. Administering methylergonovine is not appropriate for a fourth-degree perineal laceration.
Methylergonovine is typically used to prevent or treat postpartum hemorrhage by promoting uterine contractions.
B. Applying povidone-iodine to the client's perineum is not indicated for the management of a perineal laceration. Povidone-iodine is an antiseptic solution used for wound cleansing, but it may be too harsh for the perineal area.
C. Providing the client with a cool sitz bath is appropriate for managing discomfort and promoting healing after a fourth-degree perineal laceration. A sitz bath helps to soothe the perineal area and reduces inflammation.
D. Applying a moist, warm compress to the perineum is not recommended for a fourth-degree perineal laceration, as it may increase the risk of infection and discomfort.
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