The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales?
Select one:

Vitamin K will increase erythropoiesis.

Vitamin K will enhance bilirubin breakdown.

Vitamin K will stop Rh sensitization.

Vitamin K will promote blood clotting ability. Vitamin K will promote blood clotting ability.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Vitamin K will increase erythropoiesis. This is an incorrect statement that confuses vitamin K with erythropoietin. Erythropoietin is a hormone that stimulates red blood cell production in the bone marrow. Vitamin K does not aﬀect erythropoiesis.

Choice B Reason: Vitamin K will enhance bilirubin breakdown. This is an incorrect statement that confuses vitamin K with phototherapy. Phototherapy is a treatment that exposes the newborn's skin to light, which converts bilirubin into water-soluble forms that can be excreted by the liver and kidneys. Bilirubin is a yellow pigment that results from the breakdown of red blood cells. High levels of bilirubin can cause jaundice and brain damage in newborns. Vitamin K does not aﬀect bilirubin metabolism.

Choice C Reason: Vitamin K will stop Rh sensitization. This is an incorrect statement that confuses vitamin K with Rh immune globulin. Rh immune globulin is an injection given to Rh-negative mothers who deliver Rh-positive babies, to prevent them from developing antibodies against Rh-positive blood cells in future pregnancies. Rh sensitization is a condition where the mother's immune system atacks the baby's blood cells, causing hemolytic disease of the newborn. Vitamin K does not aﬀect Rh sensitization.

Choice D Reason: Vitamin K will promote blood clotting ability. This is a correct statement that explains the rationale for administering vitamin K as prophylaxis to newborns. Vitamin K is essential for the synthesis of clotting factors in the liver. Newborns have low levels of vitamin K at birth due to poor placental transfer and lack of intestinal bacteria that produce vitamin K. Therefore, they are at risk of bleeding disorders such as hemorrhagic disease of the newborn.

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Correct Answer is B

Explanation

Choice A Reason: Prepare for IV dextrose administration. This is an incorrect answer that indicates an unnecessary and invasive intervention for an IDM with normal blood glucose. IV dextrose administration is indicated for an IDM with severe or persistent hypoglycemia, which is defined as a blood glucose below 40 mg/dL or below 60 mg/dL after two feedings.

Choice B Reason: Provide routine care, per hospital IDM protocol. This is because a blood glucose of 60 is within the normal range for an IDM, which is 40 to 80 mg/dL. An IDM is a newborn whose mother has pre-existing or gestational diabetes, which can aﬀect the fetal and neonatal glucose metabolism and regulation. An IDM may have hypoglycemia (low blood glucose), hyperglycemia (high blood glucose), or other complications such as macrosomia, polycythemia, or congenital anomalies. An IDM requires routine care and monitoring according to the hospital IDM protocol, which may include blood glucose testing, feeding, temperature regulation, and observation for signs of distress.

Choice C Reason: Place the infant in a warmed incubator. This is an incorrect answer that suggests an irrelevant and potentially harmful action for an IDM with normal blood glucose. Placing the infant in a warmed incubator is indicated for an IDM with hypothermia, which is a low body temperature that can impair glucose utilization and increase oxygen consumption. However, placing the infant in a warmed incubator without proper indication can cause hyperthermia, which is a high body temperature that can lead to dehydration, electrolyte imbalance, or brain damage.

Choice D Reason: Alert the clinician immediately for orders. This is an incorrect answer that implies an urgent and unwarranted situation for an IDM with normal blood glucose. Alerting the clinician immediately for orders is indicated for an IDM with signs of distress or complications, such as apnea, cyanosis, seizures, or jaundice.

A. Physiologic anemia due to maternal increased plasma volume. B. Pressure of the gravid uterus on the maternal inferior vena cava and aorta. C. Pressure of the presenting fetal part on the maternal diaphragm. D. A 50% increase in maternal blood volume during pregnancy.

Correct Answer is B

Explanation

Choice A Reason: Physiologic anemia due to maternal increased plasma volume. This is an incorrect answer that refers to a diﬀerent condition that aﬀects hemoglobin levels, not blood pressure. Physiologic anemia is a condition where the maternal plasma volume increases more than the red blood cell mass during pregnancy, which dilutes the hemoglobin concentration and lowers the hematocrit value. Physiologic anemia does not cause significant symptoms or complications in pregnant women, as it is an adaptive mechanism that enhances oxygen delivery and prevents ﬂuid overload.

Choice B Reason: Pressure of the gravid uterus on the maternal inferior vena cava and aorta. This is because this statement explains the cause of supine hypotensive syndrome, which is a condition where lying ﬂat on the back causes compression of the major blood vessels by the gravid uterus, which reduces venous return and cardiac output, which lowers blood pressure and perfusion to vital organs. Supine hypotensive syndrome can cause symptoms such as dizziness, lightheadedness, nausea, pallor, or syncope in pregnant women, especially in the third trimester.

Choice C Reason: Pressure of the presenting fetal part on the maternal diaphragm. This is an incorrect answer that indicates a diﬀerent condition that aﬀects respiratory function, not blood pressure. Pressure of the presenting fetal part on the maternal diaphragm is a result of cephalic engagement or lightening, which occurs when the fetal head descends into the pelvis and occupies more space in the abdominal cavity. Pressure of the presenting fetal part on the maternal diaphragm can cause symptoms such as dyspnea, heartburn, or rib pain in pregnant women.

Choice D Reason: A 50% increase in maternal blood volume during pregnancy. This is an incorrect answer that describes a normal physiological change that occurs during pregnancy, not a cause of supine hypotensive syndrome. A 50% increase in maternal blood volume during pregnancy is due to increased production of plasma and red blood cells, which helps meet the increased oxygen and nutrient demands of the fetus and placenta, and prepares the mother for blood loss during delivery. A 50% increase in maternal blood volume during pregnancy does not cause hypotension or dizziness in pregnant women.

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The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales? Select one:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Select one: