A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer?

(Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.)

Choice A reason: Plan of care changes for the upcoming shift

Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.

Choice B reason: Intracranial pressure readings

Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.

Choice C reason: Glasgow results

The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.

Choice D reason: Code status

Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.

Choice A Reason:

Vesicles on the skin are more commonly associated with cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax typically presents with a raised, itchy bump that develops into a painless sore with a black center.

Choice B Reason:

Respiratory failure is a severe and common symptom of inhalation anthrax. Inhalation anthrax begins with flu-like symptoms but can rapidly progress to severe respiratory distress, shock, and often death if not treated promptly.

Choice C Reason:

Flu-like symptoms are indeed an early sign of inhalation anthrax, but they are not specific enough to indicate exposure definitively. These symptoms include sore throat, mild fever, fatigue, and muscle aches.

Choice D Reason:

Coughing of blood can occur in the later stages of inhalation anthrax as the disease progresses and the respiratory system becomes severely compromised.