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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clear the respiratory tract. This is because clearing the respiratory tract is the first step in the initial care of a newborn following vaginal delivery. The respiratory tract includes the nose, mouth, and lungs.
Clearing the respiratory tract helps the baby breathe more easily and prevents aspiration of amniotic fluid, blood, or mucus. The nurse can use a bulb syringe or a suction device to gently remove any fluid from the baby's nose and mouth.
Choice B is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.
Choice C is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.
Choice D is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.
Correct Answer is A
Explanation
Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.
Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.
Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.
Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.
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