A nurse is preparing to administer Vitamin K to a newborn. The doctor has ordered a needle for the injection. Which of the following is the most appropriate action for the nurse to take when preparing to administer the injection?

Appeared in: NORCET 7 Prelims -2024

Explanation

The standard of care, recommended by pediatric associations, is to administer a single prophylactic dose of Vitamin K via the intramuscular (IM) route.
This route ensures reliable absorption and effective prevention of Vitamin K Deficiency Bleeding (VKDB), a serious condition in newborns.
A 26-gauge needle is an appropriate size for delivering the medication into the vastus lateralis muscle of a newborn, minimizing tissue trauma while ensuring proper depth.

Option A: Subcutaneous administration is not the standard route for routine prophylaxis as IM absorption is more consistent and reliable for preventing VKDB.
Option C: Intravenous (IV) administration carries a risk of severe adverse reactions, including anaphylaxis, and is not used for routine prophylaxis.
Option D: Intradermal administration (into the dermis) is an incorrect route for Vitamin K. This shallow injection route is used for sensitivity testing or certain vaccines.

Clinical Relevance

Nursing practice connection: Knowing Route of Administration for Newborn Vitamin K Prophylaxis helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Correctly administering Vitamin K via the IM route is a critical nursing action to prevent VKDB, which can cause life-threatening bleeding, including intracranial hemorrhage.
Accurate documentation of the administration is crucial for patient safety to prevent missed doses or accidental re-dosing.
What if the newborn is premature? Premature infants also receive Vitamin K, but the dose may be adjusted based on birth weight (e.g., 0.3 mg/kg for infants weighing less than 1 kg) to reduce risks, though the IM route remains standard.

How to Approach the Question

First, identify the core of the question: the correct procedure for administering Vitamin K to a newborn.
Recall the standard of care for newborn medications. Vitamin K is a routine prophylactic injection.
Evaluate each option based on the route of administration (subcutaneous, intramuscular, intravenous, intradermal).
Eliminate routes that are incorrect for this specific medication and patient. IV is for emergencies, intradermal is for testing, and subcutaneous is not the standard.
Confirm that the intramuscular route is the correct and most common practice for newborn Vitamin K, making the corresponding option the answer.

Concept Tested & Keywords

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E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 3 (pp 477-702 of 713) p. 179-181

E6 Nursing Fundamentals Taylor p. 862-864

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 174-176

Practise the full NORCET 7 Prelims -2024

Attempt every question from this paper in a timed mock, then review the full solution for each one.