A nurse is planning to administer phytonadione 0.5 mg to a newborn.

Available is 1 mg/0.5 mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth.

Use a leading zero if it applies.

Do not use a trailing zero.)

Choice A rationale

Weighing a newborn's wet diaper is an essential component of monitoring fluid balance and renal function, which is critical as neonatal abstinence syndrome (NAS) infants may have diarrhea leading to fluid loss. However, it is not the first priority action. NAS symptoms, caused by central nervous system hyperexcitability, necessitate stabilization of vital functions, with respiratory status being paramount. Normal urine output for a newborn is typically 1-3 mL/kg/hr.

Choice B rationale

Swaddling provides non-pharmacological comfort by simulating the confined uterine environment, reducing excessive stimulation, and minimizing the hyperirritability and tremors associated with central nervous system dysfunction in neonatal abstinence syndrome. While a beneficial and frequent intervention, stabilizing the newborn's physiological status, specifically respiratory effort and rate, must be assessed and secured as the immediate priority due to potential for respiratory distress.

Choice C rationale

Determining the newborn's respiratory rate is the highest priority because respiratory depression and distress are critical potential complications in a newborn experiencing neonatal abstinence syndrome, often associated with poly-drug exposure or direct effects of opioids. NAS can lead to hyperthermia and increased metabolic demand, escalating oxygen consumption. A normal newborn respiratory rate is typically 30 to 60 breaths per minute; deviations require immediate intervention.

Choice D rationale

Auscultating the newborn's bowel sounds assesses gastrointestinal motility, which can be affected by the hyper-excitability seen in NAS, potentially leading to diarrhea, poor feeding, and fluid-electrolyte imbalances. However, this assessment is secondary to ensuring adequate oxygenation and ventilation, which is always the initial and most crucial step in the hierarchy of needs for any compromised neonate experiencing withdrawal symptoms.

Choice A rationale

While bonding time is crucial for establishing parent-newborn attachment, it is not the immediate priority during the third stage of labor. The third stage is the period from the baby's birth until the placenta is delivered. The newborn's physiological stability, particularly temperature regulation and respiratory transition, takes precedence over private bonding immediately after birth.

Choice B rationale

Applying identification bands is a critical safety measure to prevent infant abduction or mix-up. However, it is not the absolute first action the nurse should take. Thermoregulation and initial stabilization, such as drying, are the immediate priorities to prevent cold stress and ensure the newborn's physiological adaptation before applying bands or allowing prolonged bonding.

Choice C rationale

Drying the newborn with clean towels is the first and most critical action to prevent heat loss through evaporation. Immediate drying and removing the wet linens are essential for thermoregulation and preventing cold stress, which can lead to increased oxygen consumption and metabolic acidosis. This action also provides tactile stimulation, which can help initiate or sustain respirations.

Choice D rationale

Checking the newborn's axillary temperature is an essential step for monitoring thermoregulation. However, it is an assessment action that follows the intervention of drying the baby. Immediate drying is the priority to prevent heat loss and stabilize the baby's temperature; the temperature check is then used to evaluate the effectiveness of the warming measures.