A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?
Administer the medication into the deltoid muscle.
Administer the medication 12 hr after birth.
Administer the medication with a 25-gauge needle.
Check the mother's Rh factor prior to administration.
The Correct Answer is C
A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.
Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A) Incorrect- Dry, cracked skin is not typically associated with a newborn born at 43 weeks of gestation. It's more common in post-term babies.
B) Correct - Hypotonia (low muscle tone) is a possible finding in post-term newborns due to the aging placenta and potential decrease in amniotic fluid.
C) Correct - Excessive lanugo (fine, downy hair) is more likely to be present in post-term babies as they have less vernix to protect their skin.
D) Incorrect- Absent vernix might be more characteristic of a post-term newborn, but its presence or absence varies widely.
E) Correct - Long, hard nails can be a characteristic of post-term babies, as they have had more time for nail growth in the womb.
Correct Answer is A
Explanation
A) Correct - Dysuria (painful urination) could indicate a urinary tract infection (UTI) which, if left untreated, can lead to complications during pregnancy. It requires prompt evaluation and treatment.
B) Incorrect- Varicose veins and gingivitis are common discomforts during pregnancy, but they are not typically considered urgent issues.
C) Incorrect- Gingivitis (inflammation of the gums) is common during pregnancy and should be addressed, but it is not as urgent as a potential UTI.
D) Incorrect- Leukorrhea (white vaginal discharge) is a common occurrence during pregnancy and is usually not a priority concern unless it's accompanied by other symptoms.
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