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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.
Choice A. Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.
Choice B. Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.
Choice D. Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.
Correct Answer is {"dropdown-group-1":"B"}
Explanation
The Apgar score is a scoring system used by doctors and nurses to assess newborns one minute and five minutes after they are born. The score is based on five criteria: activity, pulse, grimace, appearance, and respiration, with each criterion receiving a score of 0 to 2 points.
If we apply this scoring system to the information provided, the newborn's 1- minute Apgar score would be:
Activity: 1 point (limbs flexed)
Pulse: 1 point (heart rate less than 100 beats per minute) Grimace: 1 point (facial movement/grimace with stimulation) Appearance: 1 point (body pink but extremities blue) Respiration: 1 point (irregular, weak crying)
The total score is 5 points, which is considered moderately abnormal.
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