A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

Bleeding.

Infection.

Potassium deficiency.

Hyperbilirubinemia.

Answer and Explanation

The Correct Answer is A

Choice A: The correct answer is (a) Bleeding. The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding complications. Vitamin K plays a crucial role in the synthesis of blood clotting factors, specifically factors II, VII, IX, and X. Newborns have low levels of vitamin K at birth, and it takes a few days for their bodies to start producing it. This places them at risk of developing vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including bleeding into the brain (intracranial haemorrhage). By giving the newborn a vitamin K injection, this deficiency is corrected, reducing the risk of bleeding complications.

Choice B rationale

(b) Infection. Administering vitamin K to a newborn is not intended to prevent infections. Vitamin K is essential for blood clotting and does not have a direct role in preventing or treating infections. Infection prevention measures involve proper hygiene practices and vaccination, but vitamin K is unrelated to this aspect of care.

Choice C rationale

(c) Potassium deficiency. Administering vitamin K to a newborn has no impact on potassium levels. Potassium is a different essential nutrient that plays a vital role in various physiological processes, but it is not related to blood clotting. The administration of vitamin K is specific to preventing bleeding complications, not addressing potassium deficiency.

Choice D rationale

(d) Hyperbilirubinemia. The correct answer is not (d) Hyperbilirubinemia. Vitamin K administration is not aimed at preventing or treating hyperbilirubinemia, a condition characterized by elevated levels of bilirubin in the blood. Hyperbilirubinemia is related to the breakdown of red blood cells and the liver's ability to process bilirubin, whereas vitamin K's primary role is in the clotting cascade.

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Correct Answer is C

Explanation

Choice A (7) rationale: The nurse should not select 7 as the Apgar score because the newborn exhibited several positive signs at 5 minutes after birth, such as a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, indicating good muscle tone and reflexes.

Choice B (8) rationale: Choice B can be eliminated as the correct answer because the newborn displayed more than just moderate signs of normal adaptation. With a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, as well as acrocyanosis and a grimace when suctioned, the newborn shows excellent adaptation to extrauterine life.

Choice C (9) rationale: The nurse should select Choice C as the correct answer. At 5 minutes after birth, the newborn's Apgar score would be 9 because it exhibited good overall adaptation with a heart rate of 130/min, a lusty cry with tactile stimulation, flexed extremities, and some acrocyanosis and grimace when suctioned.

Choice D (10) rationale: Choice D (10) should be excluded as the correct answer since the newborn had acrocyanosis and a grimace when suctioned, which indicates some minor difficulty in adapting to the new environment.

A. The client is Rh positive and the newborn is Rh negative. B. The client is Rh negative and the newborn is Rh positive. C. The client is Rh negative and the newborn is Rh negative. D. The client is Rh positive and the newborn is Rh positive.

Correct Answer is B

Explanation

Choice A rationale:

If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.

Choice B rationale:

This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.

Choice C rationale:

If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.

Choice D rationale:

If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.

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A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is B

Explanation

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