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 protocol for preventing Vitamin K Deficiency Bleeding (VKDB) in newborns is a single dose of Vitamin K administered intramuscularly (IM).
The IM route provides consistent and reliable absorption, which is critical for effective prophylaxis against hemorrhage.
The vastus lateralis muscle (anterolateral thigh) is the recommended site for IM injections in newborns due to its size and distance from major nerves and blood vessels.
A 26-gauge needle is an appropriate size for delivering an IM injection to a newborn, balancing effective muscle penetration with minimal tissue trauma.

Option A: Subcutaneous (SC) administration is not the standard route for routine Vitamin K prophylaxis because its absorption can be slower and less reliable compared to the intramuscular route.
Option C: Intravenous (IV) administration is not used for routine prophylaxis due to the increased risk of serious adverse effects, including anaphylaxis.
Option D: The intradermal (ID) route injects medication into the dermis, just below the epidermis. This route allows for very slow absorption and is not appropriate for Vitamin K.

Visual 1: Diagram - An illustration showing the anatomical location of the vastus lateralis muscle on a newborn's thigh, with landmarks for correct injection.
Visual 2: Infographic - A comparative chart showing the different angles of needle insertion for Intradermal (10-15°), Subcutaneous (45°), and Intramuscular (90°) injections.

Clinical Relevance

Nursing practice connection: Knowing Route of Administration for Vitamin K in Newborns helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Administering prophylactic Vitamin K is a critical nursing intervention to prevent Vitamin K Deficiency Bleeding (VKDB), which can cause severe, life-threatening hemorrhage, including intracranial bleeding.
Nurses must be proficient in locating the vastus lateralis muscle and using the correct technique to ensure patient safety and medication efficacy.
What if? If a parent refuses the Vitamin K injection for their newborn, the nurse's priority is to provide clear, evidence-based education on the risks of VKDB. The refusal must be documented according to hospital policy, and the healthcare provider must be notified immediately.

How to Approach the Question

First, identify the key components of the question: the medication (Vitamin K), the patient (a newborn), and the task (administering an injection).
This is a clinical procedure question. Recall the standard, evidence-based protocol for this specific intervention.
Systematically evaluate each option based on the route of administration.
Eliminate the routes that are incorrect for routine prophylaxis in a newborn. Intravenous (IV) is for emergencies, Intradermal (ID) is for testing, and Subcutaneous (SC) offers less reliable absorption.
Select the option that aligns with the established best practice, which is intramuscular (IM) injection for prophylactic Vitamin K.

Concept Tested & Keywords

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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.