A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?
This medication prevents your baby from developing bleeding problems."
"This medication enhances regulation of your baby's temperature."
"This medication enhances your baby's immune response."
"This medication prevents your baby from developing jaundice
The Correct Answer is A
Choice A Reason:
"This medication prevents your baby from developing bleeding problems." This is the correct statement. Phytonadione is given to newborns to prevent neonatal vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including intracranial hemorrhage.
Choice B Reason:
"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.
Choice C Reason:
"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.
Choice D Reason:
"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Inserting the probe with a straight, forward motion is not correct because the ear canal is curved, and this technique could lead to inaccurate readings or discomfort.
Choice B Reason:
The AP positions the client facing her. The position of the client's face is not relevant to taking a tympanic temperature. The client can face any direction during the procedure.
Choice C Reason:
Pulling the pinna up and back straightens the ear canal in adults, allowing for a more accurate reading when taking a tympanic temperature.
Choice D Reason:
Pointing the probe posteriorly is incorrect as the probe should be pointed towards the tympanic membrane, which usually requires slight angling to align with the ear canal.
Correct Answer is A
Explanation
Choice A Reason:
Planning to remove the restraints as soon as the client is calm is a correct action. Restraints should be used for the shortest duration necessary to ensure safety. Once the client is calm and no longer poses a risk to themselves or others, the restraints should be removed promptly.
Choice B Reason:
Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward.
Choice C Reason:
Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior.
Choice D Reason:
Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.
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