A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?
Administer the medication into the deltoid muscle.
Administer the medication 12 hr after birth.
Administer the medication with a 25-gauge needle.
Check the mother's Rh factor prior to administration.
The Correct Answer is C
A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.
Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Keeping the car seat rear-facing is recommended until your baby reaches the age of 2 or the weight and height limits specified by the car seat manufacturer. This is to provide maximum protection to the baby's developing head and neck.
B) Incorrect- Placing the shoulder harness at the level of the baby's shoulders is important, but the rear-facing position is a higher priority.
C) Incorrect- The retainer clip should be positioned at the level of the baby's armpits to ensure proper placement of the harness straps.
D) Incorrect- The angle of recline is important to prevent the baby's head from flopping forward, but the rear-facing position itself is more crucial.
Correct Answer is C
Explanation
A) Incorrect- Checking urine for ketones is not necessary if the newborn's blood glucose level is low but stable and the baby is asymptomatic.
B) Incorrect- Administering glucagon is not indicated for an asymptomatic newborn with a low but stable blood glucose level.
C) Correct - Encouraging additional feeding is appropriate for an asymptomatic newborn with a low blood glucose level. Regular feeding can help increase blood glucose levels.
D) Incorrect- Waiting 4 hours to recheck blood glucose might not be appropriate if the baby's blood glucose is currently low. Addressing the low blood glucose level is more immediate.
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