A nurse is caring for a newborn who did not receive vitamin K injection at birth due to parental refusal.
Which of the following signs and symptoms should alert the nurse to a possible vitamin K deficiency bleeding (VKDB)?
Petechiae, ecchymosis, or oozing from puncture sites
Pallor, tachycardia, or poor perfusion
Jaundice, dark urine, or clay-colored stools
Hypoglycemia, lethargy, or jitteriness
The Correct Answer is A
The correct answer is choice A. Petechiae, ecchymosis, or oozing from puncture sites are signs and symptoms of vitamin K deficiency bleeding (VKDB) in newborns. VKDB is a rare form of bleeding disorder that affects newborns and young infants due to low stores of vitamin K at birth. Vitamin K is a substance that our body needs to form clots and to stop bleeding.
Choice B is wrong because pallor, tachycardia, or poor perfusion are signs of anemia or shock, which can have many causes other than VKDB.
Choice C is wrong because jaundice, dark urine, or clay-colored stools are signs of liver disease or biliary obstruction, which can affect vitamin K absorption but are not specific for VKDB.
Choice D is wrong because hypoglycemia, lethargy, or jitteriness are signs of low blood sugar or neonatal abstinence syndrome, which are not related to VKDB.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The correct answer is choice A. This injection will help prevent your baby from developing a bleeding disorder caused by low vitamin K levels.
Vitamin K is essential for the synthesis of clotting factors in the liver.
Newborns have low levels of vitamin K because it does not cross the placenta well and they have limited gut flora to produce it.
Therefore, they are at risk of vitamin K deficiency bleeding (VKDB), which can cause serious and potentially fatal hemorrhages.To prevent VKDB, the American Academy of Pediatrics recommends a single intramuscular dose of 1 mg of vitamin K to all newborn infants within 6 hours of birth.
Choice B is wrong because vitamin K does not boost the immune system or protect from infections.
Choice C is wrong because vitamin K does not stimulate liver function or metabolism.
Choice D is wrong because vitamin K does not increase appetite or growth.
Correct Answer is C
Explanation
The correct answer is choice C. Check the medication label for the name, dose, expiry date and route of administration.
This is a standard precaution that should be taken before administering any medication to ensure patient safety and avoid medication errors.
Choice A is wrong because checking the newborn’s blood type and Rh factor is not necessary before giving vitamin K injection.
Vitamin K is not a blood product and does not depend on blood compatibility.
Choice B is wrong because checking the newborn’s bilirubin level and jaundice score is not relevant to vitamin K injection.Vitamin K is given to prevent vitamin K deficiency bleeding (VKDB), which is a serious condition that can cause bleeding in the brain or other organs.
Bilirubin level and jaundice score are indicators of neonatal jaundice, which is a common condition that causes yellowing of the skin and eyes due to excess bilirubin in the blood.
Choice D is wrong because checking the newborn’s weight and length measurements is not required before giving vitamin K injection.The recommended dose of vitamin K for newborns weighing more than 1500 g is 1 mg as a single intramuscular injection within 6 hours of birth.For preterm infants weighing less than 1500 g, the dose is 0.3 mg/kg to 0.5 mg/kg.
The dose does not depend on the exact weight or length of the newborn.
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