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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Inserting a Foley catheter can relieve the bladder and provide an opportunity to monitor urinary output, which is essential for assessing the patient's condition with a perineal hematoma.
Choice B rationale
A Sitz bath may help with pain relief and hygiene but does not address the immediate concern of urinary retention and assessment for injury.
Choice C rationale
Monitoring the fundal height is important but does not address the urgent need to relieve the patient's inability to urinate.
Choice D rationale
Applying a heating pad to the area may help with pain, but it does not address the immediate problem of urinary retention due to the hematoma.
Correct Answer is B
Explanation
Choice A rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice B rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice C rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
Choice D rationale
The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.
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