A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.

Choice A rationale

Documenting the vital signs in the medical record is appropriate as the vital signs provided fall within expected ranges for a postpartum client. A temperature of 100.4°F (38°C) can be normal due to dehydration or exertion from labor, and bradycardia (heart rate 58 beats/minute) is common in postpartum women due to increased stroke volume and cardiac output.

Choice B rationale

Assessing the perineum for excessive lochia is important if there are concerns about postpartum hemorrhage, but it is not directly related to the provided vital signs. While lochia should be monitored, the vital signs alone do not indicate excessive bleeding or other complications.

Choice C rationale

Administering acetaminophen for a temperature of 100.4°F (38°C) may not be necessary, as this temperature can be considered within normal limits postpartum. Fever above 100.4°F may warrant medication, but the provided vital signs suggest no immediate need for intervention.

Choice D rationale

Reporting the heart rate to the healthcare provider is unnecessary because bradycardia (heart rate 58 beats/minute) is normal in postpartum women. Increased stroke volume during the postpartum period can result in lower heart rates. The vital signs provided do not indicate a cause for concern.