A nurse is preparing to administer vitamin K 1mg IM to a newborn.
Available is vitamin K injection 1 mg/0.5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth.
Use a leading zero if it applies.
Do not use a trailing zero.).

Choice C rationale:

The client's blood pressure of 170/101 mm Hg is significantly elevated. This is a systolic blood pressure above 160 mm Hg and a diastolic blood pressure above 110 mm Hg, which is indicative of severe hypertension. Elevated blood pressure during pregnancy can be a sign of preeclampsia, a condition that can have serious consequences for both the mother and the fetus. Therefore, the nurse should report this finding to the provider immediately. Choice C is the correct answer.

Choice D rationale:

Visual disturbances, such as blurred vision, can be an early symptom of preeclampsia. These symptoms, in combination with the elevated blood pressure, are concerning and should be reported to the provider promptly. Visual disturbances can be a sign of central nervous system involvement in preeclampsia. Choice D is the correct answer.

Choice E rationale:

Blood pressure is a vital sign that should be closely monitored during pregnancy. The elevated blood pressure of 170/101 mm Hg is a critical finding and should be reported to the provider immediately. Elevated blood pressure is one of the key diagnostic criteria for preeclampsia. Choice E is the correct answer.

Choice A rationale:

While changes in respiratory rate can be significant, they are not the primary concern in this scenario. The more pressing issues are the elevated blood pressure and visual disturbances, which are strongly indicative of preeclampsia. Choice A is not the most critical finding in this case.

Choice B rationale:

Fetal heart rate (FHR) of 148 is within the normal range for a fetus. FHR monitoring is important, but in this case, the mother's condition and vital signs take precedence due to the potential risks associated with preeclampsia. Choice B is not the most critical finding in this situation.

Choice F rationale:

Deep tendon reflexes are reported as 3+, which can be a sign of hyperreflexia, a neurological symptom associated with preeclampsia. However, the most immediate concerns in this case are the elevated blood pressure, visual disturbances, and signs of preeclampsia. Choice F is not the most critical finding in this context.

Choice A rationale:

The purpose of administering vitamin K to a newborn is to prevent bleeding. Vitamin K plays a crucial role in blood clotting. Newborns often have lower levels of vitamin K, which can make them more susceptible to bleeding disorders, such as hemorrhagic disease of the newborn (HDN). HDN can lead to serious bleeding complications, including intracranial hemorrhage, which can be life-threatening.

Choice B rationale:

Hyperbilirubinemia is not the primary purpose of administering vitamin K. While vitamin K can indirectly help in preventing jaundice (hyperbilirubinemia) by reducing the risk of bleeding that may lead to hemolysis, it is not the primary aim of vitamin K administration.

Choice C rationale:

Potassium deficiency (hypokalemia) is not a primary concern related to vitamin K administration. Vitamin K is specifically administered to prevent bleeding disorders and not to address potassium levels.

Choice D rationale:

Infection is not related to the administration of vitamin K. Vitamin K is not used to prevent or treat infections in newborns; its primary role is in blood clotting.