A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.

Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.

Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.

Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.

The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.

Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.

Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.

Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.