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.

Answer and Explanation

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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Correct Answer is C

Explanation

A) Incorrect- Leakage of fluid is possible but not a primary focus of post-procedure instructions.
B) Incorrect- Milk of magnesia is not relevant to an amniocentesis procedure.

C) Correct - Reporting uterine contractions after the procedure is important as it could indicate a potential complication, such as preterm labor.
D) Incorrect- Blood work drawn before the procedure is not typically part of the amniocentesis process.

A. Use a lancet to puncture the inner aspect of the newborn's heel. B. Leave the newborn's heel open to the air after the puncture. C. Apply an antiseptic to the newborn's heel after collecting the specimen. D. Warm the newborn's heel for 5 to 10 min before the puncture.

Correct Answer is A

Explanation

A) Correct - Newborn screening typically involves a heel stick using a lancet to collect a few drops of blood from the inner aspect of the newborn's heel.
B) Incorrect- Leaving the newborn's heel open to the air after the puncture is not necessary; a small bandage is typically applied.
C) Incorrect- An antiseptic is not typically applied after collecting the specimen, as it could interfere with the accuracy of the screening tests.
D) Incorrect- Warming the newborn's heel is not a standard step before collecting a specimen for newborn screening.

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A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about an amniocentesis with a client who is at 34 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is preparing to collect a specimen for newborn screening. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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