The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?
A.
Confirming that the newborn is at least 24 hours old.
B.
Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration.
C.
Assessing the dorsogluteal muscle as the preferred site for injection.
D.
Confirming that the newborn’s mother has been infected with the HBV.
The Correct Answer and Explanation is:
The correct intervention is:
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration.
Explanation
When administering the hepatitis B virus (HBV) vaccine to a newborn, it’s crucial to follow specific guidelines to ensure effective vaccination and the safety of the infant. Let’s examine each option:
A. Confirming that the newborn is at least 24 hours old.
- Incorrect. The hepatitis B vaccine can be given to a newborn immediately after birth, regardless of the age of the baby. In fact, the vaccine is recommended within 24 hours of birth for all infants to reduce the risk of HBV infection, particularly in cases where the mother is HBV-positive or of unknown HBV status.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration.
- Correct. The hepatitis B vaccine is typically administered intramuscularly. For newborns, the preferred needle size is a 25-gauge, 5/8-inch needle. This size ensures that the vaccine is delivered into the muscle tissue effectively while minimizing discomfort for the infant.
C. Assessing the dorsogluteal muscle as the preferred site for injection.
- Incorrect. The dorsogluteal muscle is not recommended for intramuscular injections in newborns due to the risk of sciatic nerve injury and difficulty in locating the muscle accurately. The preferred site for administering the hepatitis B vaccine to newborns is the vastus lateralis muscle of the thigh, which is more accessible and safer for infants.
D. Confirming that the newborn’s mother has been infected with the HBV.
- Incorrect. While it is important to know the maternal HBV status to guide further management, the hepatitis B vaccine is routinely given to all newborns regardless of the mother’s HBV status. If the mother is HBV-positive, the newborn will also receive hepatitis B immune globulin (HBIG) in addition to the vaccine.
In summary, option B is the correct intervention because it adheres to the recommended needle size and gauge for administering the hepatitis B vaccine to newborns, ensuring the vaccine is given safely and effectively.