A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?
Sepsis.
Tachypnea.
Bleeding.
Jaundice.
The Correct Answer is C
The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.
Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.
Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.
Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.
Choice A is wrong because wheat is not a latex cross-reactive food.
Choice B is wrong because strawberries are a low or undetermined cross- reactive food.
Choice C is wrong because peanuts are a low or undetermined cross-reactive food.
Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.
Correct Answer is A
Explanation
Face the client at eye level when communicating.
This is because eye contact helps to establish rapport and trust with the client who has dementia and shows respect and attention. Facing the client at eye level also reduces distractions and background noise that might interfere with communication.
Choice B is wrong because offering correction of incorrect client statements can increase confusion, frustration, and agitation in the client who has dementia. Instead of correcting the client, the nurse should acknowledge their feelings and try to understand their perspective.
Choice C is wrong because reorienting the client to date and time with each encounter can be stressful and ineffective for the client who has dementia. Reorientation may work in the early stages of dementia, but as the disease progresses, the client may lose their ability to retain new information and may become more disoriented. Instead of reorienting the client, the nurse should use orienting names or labels whenever possible, such as “Your son, Jack” .
Choice D is wrong because avoiding using gestures when communicating with the client who has dementia can limit the nurse’s ability to convey meaning and emotion. Gestures can help to supplement verbal communication and provide cues for the client who has difficulty understanding words. However, the nurse should avoid using gestures that might be misinterpreted or threatening to the client, such as pointing or waving .
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