The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Using a 21 gauge needle.

Injecting at a 45-degree angle.

Injecting 1cc of medication.

Injecting the medication into the vastus lateralis.

Answer and Explanation

The Correct Answer is D

Injecting the medication into the vastus lateralis. This is because the vastus lateralis is a large muscle in the thigh that is suitable for intramuscular injections in newborns³. The vitamin K injection helps prevent vitamin K deficiency bleeding, which is a rare but serious condition that can cause bleeding in the brain or other organs¹. The American Academy of Pediatrics recommends that all newborns receive a single intramuscular dose of 0.5 to 1 mg of vitamin K within one hour of birth².

Choice A is wrong because a 21 gauge needle is too large for a newborn's muscle. A 25 or 27 gauge needle is more appropriate.

Choice B is wrong because injecting at a 45-degree angle may not reach the muscle tissue. A 90-degree angle is more appropriate.

Choice C is wrong because injecting 1cc of medication is too much for a newborn's muscle. The recommended dose of vitamin K is 0.5 to 1 mg, which is equivalent to 0.05 to 0.1 mL.

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Correct Answer is D

Explanation

Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.

Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.

Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.

Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.

A. Monitor the newborn's blood glucose level hourly. B. Apply lotion to the newborn's skin twice per day. C. Encourage the newborn to breastfeed every 2 hr. D. Maintain the newborn in a prone position.

Correct Answer is C

Explanation

Encourage the newborn to breastfeed every 2 hr. This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.

Choice A is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.

Choice B is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.

Choice D is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.

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The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Correct Answer is D

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

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To protect newborns from infection while in the nursery, the nurse plans to:

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The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

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When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?