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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
Umbilical cord compression is a known cause of variable decelerations in the fetal heart rate. When the umbilical cord is compressed, it can temporarily disrupt blood flow and oxygen supply to the fetus, leading to decelerations. Variable decelerations often appear as abrupt, sharp drops in the fetal heart rate and are typically characterized by their unpredictable
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which can lead to late decelerations in the fetal heart rate, not variable decelerations.
Correct Answer is D
Explanation
The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.
It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.
The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.
Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.
Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).
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