A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

Instruct the mother to delay breastfeeding for 1 week.

Initiate airborne precautions.

Wait at least 24 hr before bathing the newborn.

Administer hepatitis B immune globulin IM to the newborn.

Answer and Explanation

The Correct Answer is D

A. Breastfeeding is not contraindicated in mothers with hepatitis B if the newborn receives appropriate prophylaxis.
B. Airborne precautions are not necessary; hepatitis B is transmitted through blood and body fluids, not airborne droplets.
C. Bathing the newborn does not affect hepatitis B transmission risk and does not need to be delayed.
D. Administering hepatitis B immune globulin (HBIG) IM to the newborn within 12 hours of birth, along with the first dose of the hepatitis B vaccine, is essential to prevent vertical transmission of hepatitis B virus.

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Correct Answer is B

Explanation

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.

A. Give IM injection of methylergonovine. B. Assist the client to a knee-chest position. C. Administer oxygen at 2 L/min via nasal cannula. D. Start an IV bolus of dextrose water

Correct Answer is A

Explanation

A. Administering methylergonovine (Methergine) intramuscularly is appropriate for treating postpartum hemorrhage, as it stimulates uterine contractions to help control bleeding.
B. The knee-chest position is not indicated for postpartum hemorrhage and does not address the underlying cause.
C. Oxygen may be necessary if the client is unstable, but 2 L/min via nasal cannula is not the primary intervention and may not be sufficient in a critical situation.
D. Dextrose water is not appropriate for fluid resuscitation during hemorrhage; isotonic fluids like normal saline or lactated Ringer’s are preferred to restore volume.

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A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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