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 C
Explanation
A) Incorrect- Taking the medication with breakfast may not ensure optimal absorption of iron, especially if the breakfast does not include a vitamin C source.
B) Incorrect- Taking the medication with the midday meal is not the best option for enhancing iron absorption.
C) Correct - Taking the medication with a glass of orange juice provides a source of vitamin C, which can improve iron absorption.
D) Incorrect- Taking the medication with milk is not recommended, as calcium in milk can interfere with iron absorption.
Correct Answer is A
Explanation
A) Correct - Reporting crackles is important because they can indicate fluid retention in the lungs, which can be a serious adverse effect of terbutaline.
B) Incorrect- Dizziness is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
C) Incorrect- Nausea is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
D) Incorrect- Tremors are a common side effect of terbutaline and might not warrant immediate reporting unless severe.
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