A nurse is assisting with the care of a newborn 1 hr following birth.

Exhibits

Select the 5 findings that the nurse should report to the provider.

Choice A reason:

Infection is not prevented by vitamin K administration. Vitamin K is needed for blood clotting, not for fighting infections. Newborns are given vitamin K injections to prevent a serious disease called hemorrhagic disease of the newborn (HDN), which is caused by bleeding in the brain or other organs.

Choice B reason:

Hyperbilirubinemia is not prevented by vitamin K administration. Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood, causing jaundice. Bilirubin is a yellow pigment that is produced when red blood cells break down. Vitamin K does not affect the production or breakdown of bilirubin.

Choice C reason:

Bleeding is prevented by vitamin K administration. Vitamin K is needed for the synthesis of several clotting factors that help stop bleeding when there is an injury. Newborns have very low levels of vitamin K in their bodies because they do not get enough from the placenta or breast milk, and they do not have enough bacteria in their intestines to produce it. This puts them at risk for VKDB, which can cause life-threatening bleeding in the brain or other organs.

Choice D reason:

Potassium deficiency is not prevented by vitamin K administration. Potassium is an electrolyte that is important for nerve and muscle function, as well as fluid balance. Vitamin K does not affect the absorption or excretion of potassium.

Choice A reason:

Heat facilitates the drainage of mucus for a premature newborn. This is incorrect because heat does not affect mucus drainage. Mucus drainage is more related to suctioning and hydration.

Choice B reason:

The newborn has a small body surface for his weight. This is incorrect because a small body surface area for weight would indicate a large newborn, not a premature one. A large newborn would have less risk of heat loss than a small one.

Choice C reason:

The newborn's temperature control mechanism is immature. This is correct because premature newborns have immature thermoregulation and are prone to hypothermia. Placing the newborn in an incubator helps maintain a stable temperature and prevent further complications.

Choice D reason:

Heat increases the flow of oxygen to the newborn's extremities. This is incorrect because heat does not directly affect oxygen delivery. Oxygen delivery is more related to ventilation, perfusion, and hemoglobin levels. The question is about a premature newborn who has signs of respiratory distress, such as nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. These signs indicate that the newborn is having difficulty breathing and may have a condition such as respiratory distress syndrome, transient tachypnea of the newborn, or meconium aspiration syndrome. The nurse should place the newborn in an incubator to provide warmth and prevent heat loss, which can worsen respiratory distress. The nurse should also monitor the newborn's vital signs, oxygen saturation, blood gases, chest x-ray, and neonatal abstinence scoring system if indicated. The nurse should be prepared to administer oxygen, surfactant, or mechanical ventilation as ordered.