The newborn diagnosed with phenylketonuria (PKU) will require long-term follow-up to assess for the development of:

Choice A:

Lidocaine gel to the umbilical stump is not a medication that the nurse should expect to administer to a newborn immediately following birth. Lidocaine gel is a topical anesthetic that is used to numb the skin before procedures such as injections or sutures. It is not indicated for the umbilical stump, which does not require any anesthesia.

Choice B:

Hepatitis B immunization is a medication that the nurse should expect to administer to a newborn immediately following birth. Hepatitis B is a viral infection that can cause liver damage and cancer. The immunization protects the newborn from contracting the infection from the mother or other sources. The immunization is given as an intramuscular injection in the anterolateral thigh within 12 hours of birth.

Choice C:

Phytonadione injection is a medication that the nurse should expect to administer to a newborn immediately following birth. Phytonadione is also known as vitamin K, which is essential for blood clotting. Newborns have low levels of vitamin K at birth, which puts them at risk of bleeding disorders such as hemorrhagic disease of the newborn. The injection is given as a single dose of 0.5 to 1 mg in the vastus lateralis muscle within 1 hour of birth.

Choice D:

Antibiotic ophthalmic ointment is a medication that the nurse should expect to administer to a newborn immediately following birth. Antibiotic ophthalmic ointment prevents eye infections caused by bacteria such as gonorrhea or chlamydia, which can be transmitted from the mother during delivery. The ointment is applied to both eyes within 1 hour of birth.

Choice E:

Haemophilus influenzae type b vaccine (Hib) is not a medication that the nurse should expect to administer to a newborn immediately following birth. Hib is a bacterial infection that can cause meningitis, pneumonia, and other serious illnesses. The vaccine protects the newborn from Hib infection, but it is not given at birth. The vaccine is part of the routine immunization schedule and is usually given at 2, 4, and 6 months of age.

Choice A reason:

Diminished deep-tendon reflexes are a sign of magnesium toxicity, not safety. Magnesium sulfate is a central nervous system depressant that can cause muscle weakness, respiratory depression, and cardiac arrest if given in excess. The nurse should monitor the client's deep-tendon reflexes and stop the infusion if they are absent or reduced.

Choice B reason:

A respiratory rate of 16/min is a normal finding and indicates that the client is not experiencing respiratory depression from magnesium sulfate. The nurse should monitor the client's respiratory rate and stop the infusion if it falls below 12/min.

Choice C reason:

A heart rate of 60/min is a normal finding and indicates that the client is not experiencing bradycardia from magnesium sulfate. The nurse should monitor the client's heart rate and stop the infusion if it falls below 50/min.

Choice D reason:

Urine output of 50 mL in 4 hr is a sign of oliguria, not safety. Magnesium sulfate can cause renal impairment and fluid retention if given in excess. The nurse should monitor the client's urine output and stop the infusion if it falls below 30 mL/hr.