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 D

Explanation

Choice A rationale

Monitoring hourly blood pressure is essential, but it is not the most crucial data in this scenario. Blood pressure monitoring can help identify maternal hypotension or hypertension, which can affect uteroplacental blood flow. However, hypotonic dystocia requires monitoring contractions to assess labor progression and effectiveness of oxytocin.

Choice B rationale

Preparing for an emergency cesarean birth is a potential intervention if labor does not progress or if fetal distress occurs. However, it is not the primary data to monitor initially. The decision for a cesarean is based on a comprehensive assessment, including fetal heart rate patterns and contraction quality.

Choice C rationale

Checking the perineum for bulging may indicate imminent delivery or fetal descent. However, in the context of hypotonic dystocia, the primary concern is evaluating contraction patterns to ensure the effectiveness of oxytocin in augmenting labor.

Choice D rationale

Monitoring the intensity, interval, and length of contractions is the most critical data in this case. Hypotonic dystocia involves weak, infrequent, or irregular contractions. Oxytocin is administered to strengthen and regularize contractions, so assessing their characteristics is crucial to determine the response to treatment and guide further interventions.

A. A. Hypoglycemia. B. Polycythemia. C. Hyperthermia. D. Hyperbilirubinemia. E. None F. None

Correct Answer is A

Explanation

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Correct Answer is A

Explanation

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