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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- Using a breast pump can actually help relieve breast engorgement by expressing excess milk, so this advice is not appropriate.
B) Incorrect- Applying ice packs to the breasts can decrease milk production and might not provide as much relief as other interventions.
C) Incorrect- Wearing a supportive, well-fitting bra is a good recommendation, but it might not provide enough relief for breast engorgement on its own.
D) Correct - Applying purified lanolin to the breasts can help soothe and moisturize the nipples, making breastfeeding more comfortable and providing relief from breast engorgement.
Correct Answer is C
Explanation
A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.
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