A mother refused to allow her son to receive the phytonadione (Mephyton) injection at birth as was stated on her birth plan.Which of the following signs or symptoms might the nurse observe in the baby as a result?

Vital signs are unstable.

Glucose levels are low.

Skin has acrocyanosis.

Circumcision site oozes blood.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Unstable vital signs in a newborn could be attributed to various causes such as infection, respiratory issues, or cardiovascular problems. It is not directly linked to the absence of phytonadione injection.

Choice B rationale

Low glucose levels in a newborn can result from conditions like prematurity, maternal diabetes, or feeding issues and are not a direct consequence of the absence of a phytonadione injection.

Choice C rationale

Acrocyanosis, a bluish discoloration of the hands and feet, is a common and benign finding in newborns due to immature blood circulation and is not related to the absence of phytonadione.

Choice D rationale

Phytonadione (vitamin K) is essential for blood clotting. Absence of this injection can lead to bleeding issues, such as oozing at circumcision sites, due to vitamin K deficiency bleeding (VKDB).

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Correct Answer is A

Explanation

Choice A rationale

Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .

A. Place the newborn in a radiant warmer. B. Monitor the newborn's blood pressure. C. Initiate phototherapy. D. Obtain blood glucose by heel stick.

Correct Answer is D

Explanation

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

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A mother refused to allow her son to receive the phytonadione (Mephyton) injection at birth as was stated on her birth plan.Which of the following signs or symptoms might the nurse observe in the baby as a result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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