A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A. Subcutaneous in the left vastus lateralis: Phytonadione is usually administered IM, not subcutaneously. The vastus lateralis muscle in the thigh is a common site for IM injections in newborns.

B. IM in the right deltoid: The deltoid muscle in the upper arm is not typically the recommended site for administering medications to newborns. The vastus lateralis muscle in the thigh is preferred for newborn IM injections due to better muscle development and blood flow.

C. IM in the left vastus lateralis: This is the correct option. Phytonadione, or Vitamin K, is routinely given to newborns to prevent vitamin K deficiency bleeding (VKDB). It's administered as an IM injection into the vastus lateralis muscle in the thigh, which is a standard practice for newborn vitamin K administration.

D. Subcutaneous in the right deltoid: Subcutaneous administration in the deltoid is not typically used for newborns, especially for medications like phytonadione that are commonly administered IM.

A. Applying hydrating lotion to the newborn's skin prior to treatment is not recommended as lotions or creams can interfere with the effectiveness of phototherapy and may increase the risk of skin irritation or burns.

B. Turning the newborn every 4 hours is insufficient; the newborn should be turned more frequently, typically every 2 hours, to ensure even exposure to the phototherapy light and to prevent pressure sores.

C. Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation.

D. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.