A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse expect to administer? (Select all that apply.).

Lidocaine gel to the umbilical stump.

Hepatitis B immunization.

Phytonadione injection.

Antibiotic ophthalmic ointment.

Haemophilus influenzae type b vaccine (Hib).

Answer and Explanation

Correct Answer : B,C,D

Choice A:

Lidocaine gel to the umbilical stump is not a medication that the nurse should expect to administer to a newborn immediately following birth. Lidocaine gel is a topical anesthetic that is used to numb the skin before procedures such as injections or sutures. It is not indicated for the umbilical stump, which does not require any anesthesia.

Choice B:

Hepatitis B immunization is a medication that the nurse should expect to administer to a newborn immediately following birth. Hepatitis B is a viral infection that can cause liver damage and cancer. The immunization protects the newborn from contracting the infection from the mother or other sources. The immunization is given as an intramuscular injection in the anterolateral thigh within 12 hours of birth.

Choice C:

Phytonadione injection is a medication that the nurse should expect to administer to a newborn immediately following birth. Phytonadione is also known as vitamin K, which is essential for blood clotting. Newborns have low levels of vitamin K at birth, which puts them at risk of bleeding disorders such as hemorrhagic disease of the newborn. The injection is given as a single dose of 0.5 to 1 mg in the vastus lateralis muscle within 1 hour of birth.

Choice D:

Antibiotic ophthalmic ointment is a medication that the nurse should expect to administer to a newborn immediately following birth. Antibiotic ophthalmic ointment prevents eye infections caused by bacteria such as gonorrhea or chlamydia, which can be transmitted from the mother during delivery. The ointment is applied to both eyes within 1 hour of birth.

Choice E:

Haemophilus influenzae type b vaccine (Hib) is not a medication that the nurse should expect to administer to a newborn immediately following birth. Hib is a bacterial infection that can cause meningitis, pneumonia, and other serious illnesses. The vaccine protects the newborn from Hib infection, but it is not given at birth. The vaccine is part of the routine immunization schedule and is usually given at 2, 4, and 6 months of age.

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Correct Answer is ["B","D","F","H"]

Explanation

Choice A reason
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.
Choice B reason
Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.
Choice C reason
Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.
Choice D reason
NAS score is not a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.
Choice E reason
Temperature is not a priority finding for a newborn with NAS. Temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.
Choice F reason
Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.
Choice G reason
Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cry, and seizures are signs of neurological dysfunction,which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.
Choice H reason
Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs.

A. Transfer the newborn to the NICU B. Call the lab for a STAT blood glucose level C. Initiate breastfeeding D. Recognize this as a normal reading and document it

Correct Answer is C

Explanation

Choice A reason:

Transferring the newborn to the NICU is not the best action to take next, because it does not address the immediate problem of low blood sugar. The newborn may need to be transferred to the NICU later, depending on the cause and severity of the hypoglycemia, but the first priority is to raise the blood glucose level.

Choice B reason:

Calling the lab for a STAT blood glucose level is not the best action to take next, because it will delay the treatment of hypoglycemia. The glucometer reading is a reliable indicator of low blood sugar, and waiting for a lab confirmation will waste valuable time. The nurse should act on the glucometer reading and initiate treatment as soon as possible.

Choice C reason:

Initiating breastfeeding is the best action to take next, because it will provide the newborn with a source of glucose that can raise the blood sugar level quickly. Breastfeeding also has other benefits for the newborn, such as promoting bonding, providing antibodies, and reducing the risk of infection. Breastfeeding should be initiated within the first hour of life for all newborns, unless contraindicated.

Choice D reason:

Recognizing this as a normal reading and documenting it is not the best action to take next, because it is not a normal reading for a 2 hour old newborn. The normal range of blood glucose for a newborn is 40 to 150 mg/dL. A reading of 32 mg/dL indicates hypoglycemia, which can have serious consequences for the newborn's brain development and function. Hypoglycemia should be treated promptly and documented accordingly.

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A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse expect to administer? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a newborn who is 72 hr old and is receiving treatment for neonatal abstinence syndrome. Exhibits Which of the following data collection findings should the nurse identify as requiring immediate follow- up? (Select all that apply.).

Correct Answer is ["B","D","F","H"]

Explanation

The nurse checks the blood sugar of a 2 hour old newborn, and the glucometer reading is 32 mg/dl. Which action should the nurse take next?

Correct Answer is C

Explanation

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