The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8° to 37° C (98.2° to 98.6° F),
and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision?
a. Consent
b. Vitamin K
c. Heart rate
d. Temperature
ANS: B
The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the infant's heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system.
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