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 D

Explanation

Choice A Reason: Respiratory rate of 16. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Respiratory rate is a measure of the number of breaths per minute, which reﬂects the respiratory function and oxygenation status. Respiratory rate of 16 is within the normal range for adults, which is 12 to 20 breaths per minute. Respiratory rate of 16 does not indicate magnesium sulfate toxicity, which can cause respiratory rate below 12 breaths per minute.

Choice B Reason: Complaints by the client of feeling ﬂushed and warm. This is an incorrect answer that indicates a common side eﬀect that does not indicate magnesium sulfate toxicity. Feeling ﬂushed and warm are sensations that are caused by vasodilation (widening of blood vessels), which can occur as a result of magnesium sulfate administration. Feeling ﬂushed and warm are not signs of magnesium sulfate toxicity, but rather expected and mild reactions that usually subside within a few hours.

Choice C Reason: Fetal heart rate of 120. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Fetal heart rate is a measure of the number of beats per minute of the fetal heart, which reﬂects the fetal well-being and oxygenation status. Fetal heart rate of 120 is within the normal range for fetuses, which is 110 to 160 beats per minute. Fetal heart rate of 120 does not indicate magnesium sulfate toxicity, which can cause fetal heart rate below 110 beats per minute or above 160 beats per minute.

Choice D Reason: Patellar reﬂexes are absent. This is because absent patellar reﬂexes are a sign of magnesium sulfate toxicity, which is a condition where the level of magnesium in the blood is too high, which can cause adverse eﬀects on the neuromuscular and cardiovascular systems. Magnesium sulfate is a medication that is used to prevent or treat preterm labor, which is labor that occurs before 37 weeks of gestation. Magnesium sulfate works by relaxing the uterine muscles and inhibiting uterine contractions. However, magnesium sulfate can also aﬀect other muscles and nerves in the body, and cause symptoms such as muscle weakness, respiratory depression, hypotension, or cardiac arrest.

A. Grunting and nasal ﬂaring. B. Acrocyanosis. C. Abdominal breathing. D. Respiratory rate of 54 breaths/minute.

Correct Answer is A

Explanation

Choice A Reason: Grunting and nasal ﬂaring. These are signs of respiratory distress in newborns, which indicate that their oxygenation needs are not being met. Grunting and nasal ﬂaring. This is because grunting and nasal ﬂaring are signs of respiratory distress in newborns, which indicate inadequate oxygenation and ventilation. Grunting is a noise made by the newborn when exhaling, which reﬂects an atempt to keep the alveoli open and increase lung volume.

Nasal ﬂaring is a widening of the nostrils when inhaling, which reﬂects an eﬀort to reduce airway resistance and increase airﬂow.

Choice B Reason: Acrocyanosis. This is not a sign of respiratory distress in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

Choice C Reason: Abdominal breathing. This is not a sign of respiratory distress in newborns, but rather a normal patern of breathing for them. Abdominal breathing means that the newborn's abdomen rises and falls with each breath, which reﬂects the use of the diaphragm as the primary respiratory muscle.

Choice D Reason: Respiratory rate of 54 breaths/minute. This is not a sign of respiratory distress in newborns, but rather a normal range of respiratory rate for them. A normal respiratory rate for a newborn ranges from 40 to 60 breaths per minute.

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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

A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity? Select one:

Correct Answer is D

Explanation

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met? Select one:

Correct Answer is A

Explanation

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Select one: