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 C

Explanation

A. The vacuum cup is positioned on the fetal head, over the flexion point, not in front of the ears.
B. Continuous fetal monitoring should be maintained during vacuum-assisted delivery.
C. The nurse should encourage the client to push during contractions to assist with the delivery.
D. A full bladder can obstruct delivery; the bladder should be emptied prior to the procedure.

A. Insert an indwelling urinary catheter immediately following the procedure. B. Apply sequential compression devices prior to the procedure. C. Perform a surgical timeout while the client is in the preoperative holding area. D. Initiate oxytocin via continuous IV infusion prior to the procedure.

Correct Answer is C

Explanation

A. An indwelling urinary catheter is typically inserted before or during the procedure, not after.
B. Sequential compression devices are important to prevent venous thromboembolism but are usually applied before or during the procedure; this option is partially correct but less critical than the timeout.
C. Performing a surgical timeout is a critical safety step conducted in the preoperative holding area to verify patient identity, procedure, and site.
D. Oxytocin is usually started after delivery to promote uterine contraction, not prior to surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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