A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?
This medication prevents your baby from developing bleeding problems."
"This medication enhances regulation of your baby's temperature."
"This medication enhances your baby's immune response."
"This medication prevents your baby from developing jaundice
The Correct Answer is A
Choice A Reason:
"This medication prevents your baby from developing bleeding problems." This is the correct statement. Phytonadione is given to newborns to prevent neonatal vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including intracranial hemorrhage.
Choice B Reason:
"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.
Choice C Reason:
"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.
Choice D Reason:
"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Urinary retention can be a side effect of opioids used in PCA, but it is not a direct indicator of unrelieved pain.
Choice B Reason:
Constipation is a potential side effect of opioid medications, but it does not directly indicate unrelieved pain.
Choice C Reason:
Difficulty swallowing is not a typical indicator of unrelieved pain but may be related to other factors such as postoperative effects or medication side effects.
Choice D Reason:
Clenched teeth can be an indicator of unrelieved pain in a client receiving patient-controlled analgesia (PCA). It suggests that the client is experiencing discomfort and may be trying to endure the pain rather than using the PCA pump to self-administer pain relief. Clients who are in pain may clench their teeth as a response to pain or discomfort.
Correct Answer is A
Explanation
Choice A Reason:
Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.
Choice B Reason:
Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.
Choice C Reason:
Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.
Choice D Reason:
Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.
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