A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

Use a 20-gauge needle to administer the vaccine.

Choose a 3/8-inch needle to administer the vaccine.

Administer the vaccine into the dorsal gluteal muscle.

Administer 0.5 mL of the vaccine.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B)   Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C)   Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D)   Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.

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Correct Answer is A

Explanation

A) Correct - Lochia serosa, a pinkish-brown vaginal discharge, is typically present 24 hours after vaginal delivery. It is the second stage of lochia that follows the bright red lochia rubra.
B) Incorrect- Frequent urges to urinate might be present but are not specific to the 24- hour postpartum period.
C) Incorrect- The uterine fundus should be descending in the days after childbirth, not located 2 finger widths above the umbilicus.
D) Incorrect- Colostrum is the early milk produced by the breasts, but its presence is not a specific finding in the immediate postpartum period.

A. Elevated blood pressure B. Leukopenia C. Hydramnios D. Ketonuria

Correct Answer is C

Explanation

A) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.

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A nurse is preparing to administer the hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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