A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?

Sepsis.

Tachypnea.

Bleeding.

Jaundice.

Answer and Explanation

The Correct Answer is C

The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.

Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.

Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.

Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.

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Correct Answer is A

Explanation

This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.

Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.

Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.

Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.

A. “Record your urination times for 24 hours before beginning the program.” B. “Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.” C. “Void every 2 hours while awake.” D. “Eliminate caffeine from your diet.”

Correct Answer is A

Explanation

This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.

Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.

Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.

Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.

However, eliminating caffeine alone may not be enough to improve urinary incontinence.

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A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection. The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has gestational diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is collecting data for a client’s health history as well as physical examination. Which of the following information should the nurse identify as a risk factor for type 2 diabetes mellitus?

A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect?

A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?

A charge nurse at a long-term care facility ensures that the workload is distributed equally among staff when making assignments. Which of the following ethical principles is the nurse upholding?

A nurse at a long-term care facility is caring for a client who has AIDS. The client accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap and water, the nurse should apply a solution of water and which of the following disinfectants to the floor?

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A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?