A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?
Subcutaneous in the right deltoid.
IM in the left vastus lateralis.
IM in the right deltoid.
Subcutaneous in the left vastus lateralis.
The Correct Answer is B
Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
-
Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
-
Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
-
Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
-
Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
-
Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
-
Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
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