A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Vitamin K was administered SUBQ in the thigh to act as a blood coagulant.

Your baby was given an injection of vitamin K to prevent bleeding.

Your baby had blood drawn to determine his hemoglobin and hematocrit levels.

We usually use the thigh when administering injections to infants.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.

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Correct Answer is A

Explanation

Choice A rationale

The symptoms of jitteriness, hypotonia, weak cry, and low temperature can indicate hypoglycemia in a newborn. Obtaining a heel stick blood glucose level is crucial to confirm the diagnosis and provide appropriate treatment.

Choice B rationale

While keeping the infant warm is important, it does not address the underlying issue of potential hypoglycemia, which needs to be identified and treated promptly.

Choice C rationale

Placing a pulse oximeter on the heel assesses oxygen saturation, which is not directly related to the symptoms described. The primary concern here is glucose level, not oxygen saturation.

Choice D rationale

Documenting the findings is important but does not provide immediate intervention for potential hypoglycemia, which requires urgent glucose level assessment and treatment if necessary. .

A. Assess the fetal heart rate and client's contraction pattern. B. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration. C. Determine fetal position by performing Leopold maneuvers. D. Perform sterile vaginal examination to determine dilatation.

Correct Answer is A

Explanation

Choice A rationale

Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.

Choice B rationale

Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.

Choice C rationale

Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.

Choice D rationale

Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .

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A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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