Correct Answer: C

Rationale: The correct response by the nurse is C. Newborn infants are born with low levels of vitamin K because they do not have enough of the gut bacteria necessary to produce it. Vitamin K plays a crucial role in blood clotting, and without enough of it, newborns are at risk of a bleeding disorder called vitamin K deficiency bleeding (VKD
B). The vitamin K injection given to newborns helps prevent this disorder by providing them with the necessary vitamin K to ensure proper blood clotting. It is important for the mother to understand that this injection is essential for her infant's health and well-being to prevent complications related to vitamin K deficiency.

Correct Answer: C

Rationale: The highest nursing priority when performing nursing care for a neonate after birth is giving the vitamin K injection. Vitamin K is essential for blood clotting, and neonates are born with low levels of this vitamin, putting them at risk for bleeding disorders. Administering the vitamin K injection helps prevent serious bleeding complications such as Vitamin K Deficiency Bleeding (VKD
B). It is crucial to give this injection as soon as possible after birth to ensure the neonate receives adequate protection. Covering the neonate's head with a cap may help maintain body temperature but is not as critical as administering the vitamin K injection. Obtaining a dextrostix or giving the initial bath are important aspects of newborn care but do not take precedence over the administration of vitamin K.

Correct Answer: A

Rationale: The initial bolus of crystalloid fluid replacement for a pediatric patient in shock is generally recommended to be 20 ml/kg. This is based on the principles of fluid resuscitation in pediatric patients to restore perfusion and improve hemodynamic stability. Administering the appropriate initial fluid bolus is crucial in treating pediatric patients in shock to avoid complications like cardiovascular collapse and multi-organ dysfunction. It is important to adjust the volume and rate of fluid administration based on the individual patient's response and ongoing assessment to prevent fluid overload.

Correct Answer: D

Rationale: Secondary vesicoureteral reflux is a condition where urine flows backward from the bladder into the ureters and possibly towards the kidneys due to an underlying cause. In the majority of cases, it results from an infection in the urinary tract, particularly in the bladder. The infection leads to inflammation and weakening of the valves that normally prevent urine from refluxing back towards the kidneys. This condition is more common in children but can also occur in adults. Treating the underlying infection is essential to managing secondary vesicoureteral reflux and preventing complications such as kidney damage.

Correct Answer: C

Rationale: Nurse Galina should recognize an open anterior fontanel as a normal finding in a 2-year-old child. The anterior fontanel is a soft spot on a baby's skull where the skull bones have not yet fused together. It usually closes by the time a child is 18 to 24 months old. The open fontanel at 2 years of age is within the normal range of closure, and it is not a cause for concern in this case. No need to notify the doctor, look for other signs of abuse, or ask about a family history of Tay-Sachs disease based on this finding.