Nokea
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and minimal nerve endings, reducing the risk of injury and increasing absorption. This site is recommended by healthcare guidelines for administering vaccines to infants to ensure proper absorption and effectiveness. The other choices are incorrect because vigorously massaging the site (B) can cause pain and tissue damage, inserting the needle at a 45° angle (C) may not reach the muscle and can cause subcutaneous injection, and using a 21-gauge needle (D) is not specific to the site and age group, potentially causing discomfort and inadequate absorption.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: Correct Answer: A) You should have your provider refit you for a new diaphragm.
Rationale: Postpartum changes in the body, such as weight fluctuations and pelvic floor tone, can affect the fit and effectiveness of a diaphragm. It is important for the client to be refitted by a healthcare provider to ensure proper sizing and optimal contraceptive efficacy.
Summary:
B) Using an oil-based vaginal lubricant can weaken the diaphragm material and increase the risk of breakage.
C) Keeping the diaphragm in place for an extended period after intercourse is not necessary and may increase the risk of toxic shock syndrome.
D) Storing the diaphragm in sterile water is not recommended as it can lead to contamination and infections.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the most appropriate response because GBS status can change throughout pregnancy, and the risk of transmitting GBS to the newborn is highest during delivery. Testing closer to the due date ensures the most accurate results.
A: Incorrect. GBS may not present with symptoms, so relying on symptoms alone is not a reliable method for testing.
B: Incorrect. Previous negative results do not guarantee current status, as GBS status can change.
C: Incorrect. Lack of indication in earlier prenatal testing does not rule out GBS at the time of delivery.
E, F, G: Not provided, but unnecessary as the correct answer has been identified.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D - To facilitate bonding between the newborn and parent. Instillation of antibiotic ointment can interfere with the bonding process between the newborn and parent, as it may create a barrier between them. Bonding is crucial for establishing a strong emotional connection and attachment between the newborn and parent, which is important for the newborn's overall well-being. Delaying the instillation allows for uninterrupted skin-to-skin contact and bonding. Choices A, B, and C are incorrect because delaying antibiotic ointment instillation does not affect the identification of infection manifestations, the newborn's weight, or the mode of delivery.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (D) can exacerbate symptoms of withdrawal and should be avoided.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns tend to have longer nails due to the prolonged gestation period. This is because the nails continue to grow during the extra time in the womb. Large deposits of subcutaneous fat (A) are more common in preterm infants. Thin covering of fine hair on shoulders and back (B) is characteristic of lanugo, which is typically shed before birth. Pale, translucent skin (D) is more commonly seen in premature babies.