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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

A. Squeeze out the white material after cleansing the face. B. Contact a pediatric dermatologist for topical medication C. Leave the milia alone: it will disappear spontaneously. No treatment is needed. D. Wash the baby's face with a mild astringent several times a day.

Correct Answer is C

Explanation

Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.

Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.

Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.

Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.

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The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Correct Answer is C

Explanation

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

Correct Answer is C

Explanation

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?