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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - "Progestin-only birth control pills are preferred for contraception during lactation." Progestin-only pills are generally considered safer for breastfeeding mothers as they are less likely to affect milk supply.
B) Incorrect- There is no strong evidence suggesting that taking birth control pills while breastfeeding increases the risk of breast cancer.
C) Incorrect- While breastfeeding can have contraceptive effects, relying solely on breastfeeding for contraception is not a foolproof method. It's recommended to use additional birth control methods if desired.
D) Incorrect- Birth control pills are not contraindicated for breastfeeding clients, especially if they are progestin-only pills. The preferred method, however, is progestin-only rather than combined hormonal pills.
Correct Answer is C
Explanation
A) Incorrect- Tachycardia (elevated heart rate) can be a common physiological response to pain or other factors and is not necessarily indicative of an adverse effect of epidural anesthesia.
B) Incorrect- Fever might be related to various factors, including infection, and is not directly indicative of an adverse effect of epidural anesthesia.
C) Correct - Tachypnea (rapid breathing) can be an adverse effect of epidural anesthesia.
It can indicate that the anesthesia has spread too high in the spinal column, potentially affecting the respiratory muscles and causing respiratory distress.
D) Incorrect- Hypertension might be a side effect of epidural anesthesia, but tachypnea is a more specific indication of an adverse effect in this context.
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