A nursery nurse is caring for a newborn who was born 2 hours ago. Upon review of the prenatal records, the nurse notes the following prenatal panel results:
A positive, Hepatitis B positive, RPR negative, Rubella immune, HIV negative, GBS positive. In addition to Vitamin K and Erythromycin ophthalmic ointment, what injection(s) should the newborn receive?
Hepatitis B vaccine only, administered within 1 hour of birth.
Hepatitis B vaccine and Hepatitis B immunoglobulin administered within 12 hours of delivery.
Hepatitis B immunoglobulin (HBIG) only, administered within 12 hours of birth.
Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by hepatitis B vaccine monthly for 12 months.
The Correct Answer is B
Choice A rationale
Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.
Choice B rationale
Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.
Choice C rationale
Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.
Choice D rationale
Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .
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Correct Answer is B
Explanation
Choice A rationale
A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.
Choice B rationale
A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.
Choice C rationale
A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.
Choice D rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.
Correct Answer is B
Explanation
Choice A rationale
An inwardly turned foot is not a sign of DDH. It may indicate a different condition such as clubfoot.
Choice B rationale
Asymmetrical gluteal folds are a common sign of developmental dysplasia of the hip (DDH). This occurs because the hip joint is not properly aligned, causing uneven skin folds.
Choice C rationale
The absence of the Babinski sign is not related to DDH. The Babinski sign is a reflex test used to assess neurological function.
Choice D rationale
The absence of the stepping reflex is not related to DDH. The stepping reflex is a normal newborn reflex that disappears after a few months.