The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?

Confirming that the newborn is at least 24 hours old.

Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration.

Assessing the dorsogluteal muscle as the preferred site for injection.

Confirming that the newborn's mother has been infected with the HBV.

Answer and Explanation

The Correct Answer is B

A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.

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Correct Answer is D

Explanation

A. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.

A. Document this as an expected finding. B. Call the provider to further assess the newborn. C. Prepare the newborn for transport to the NICU. D. Ask another nurse to verify the heart rate.

Correct Answer is A

Explanation

A. An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B. Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D. Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.

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The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new mother states that her infant must be cold because the baby’s hands and feet are blue. This common and temporary condition is called what?

Correct Answer is D

Explanation

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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