A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

Proper procedure for a heel stick includes:

A) Confirming the newborn's identity before any procedure. the nurse should confirm the newborn's identity by checking the identification band and asking the mother or caregiver to verify the name and date of birth.
E) The nurse should warm the newborn's heel by placing a warm compress or a heel warmer on the site for 3 to 5 minutes. This will increase blood flow and reduce pain.
B) Cleansing the site with an antiseptic to reduce the risk of infection. the nurse should cleanse the site with an antiseptic, such as alcohol or chlorhexidine, and let it air dry. The nurse should avoid using iodine, as it can interfere with some laboratory tests.

C) The nurse should pierce the newborn's heel with a sterile lancet, making sure to avoid the central area of the heel, where there are more nerves and bones. The nurse should use a single-use device that retracts automatically after use to prevent needlestick injuries.
D) The nurse should apply gentle pressure to the site with dry gauze to facilitate blood flow and collect the specimen in the appropriate container. The nurse should avoid squeezing or milking the site, as this can cause hemolysis or tissue damage.
E) The nurse should label the specimen with the newborn's name, date of birth, date and time of collection, and type of test. The nurse should also document the procedure in the newborn's chart, noting any difficulties or complications.