A nurse is educating student nurses about Vitamin K administration in newborns.
Which fact is correct?
Vitamin K aids in digestion and nutrient absorption.
Vitamin K prevents potentially life-threatening intracranial hemorrhage.
Vitamin K is required per state mandate for all preterm infants.
Vitamin K is only beneficial for male infants undergoing a circumcision.
The Correct Answer is B
Choice A rationale
Vitamin K is a fat-soluble vitamin essential for synthesizing coagulation factors in the liver, specifically factors II, VII, IX, and X, thereby preventing bleeding. Its primary function is in hemostasis, not digestion or nutrient absorption. Digestion of fats relies on bile salts and lipase, while nutrient absorption primarily occurs across the intestinal wall epithelia.
Choice B rationale
Vitamin K is routinely administered to newborns to prevent Vitamin K Deficiency Bleeding (VKDB), which can present as severe and potentially life-threatening hemorrhage, particularly within the skull (intracranial hemorrhage). Newborns have low stores of Vitamin K at birth and lack the gut flora necessary for endogenous synthesis, making supplementation critical to support clotting factor production.
Choice C rationale
While Vitamin K is standard prophylactic care for all newborns to prevent bleeding disorders, its administration is not mandated by all state laws exclusively for preterm infants. It is universally recommended for all newborns, regardless of gestational age, due to their physiologically low levels of circulating clotting factors and impaired synthesis.
Choice D rationale
The rationale for Vitamin K administration is to prevent systemic bleeding due to low coagulation factor levels; it is a vital intervention for all newborns. While it does support the coagulation needed to prevent excessive bleeding during circumcision, its benefit extends to preventing spontaneous hemorrhages in all infants, regardless of sex or planned procedures. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A uterine hematoma typically presents with unrelenting pain and may cause signs of hypovolemic shock, which would be evidenced by tachycardia and hypotension, not necessarily a displaced, high fundus as a primary sign. While a Complete Blood Count (CBC) can detect associated anemia (normal hemoglobin is 12-16 g/dL), the immediate priority is addressing the fundus's position.
Choice B rationale
A full or distended urinary bladder pushes the uterus superiorly and laterally, commonly to the right side due to anatomical arrangement, causing it to be palpable above the expected level. This displacement inhibits proper uterine contraction and increases the risk of postpartum hemorrhage. The most appropriate initial intervention is to have the woman void or catheterize her, then reassess the fundus's position and tone.
Choice C rationale
While prolonged positioning can influence physical findings, the bladder's mechanical displacement of the uterus is a more common and clinically significant cause of a fundus displaced high and to the side in the immediate postpartum period. Simply changing position will not resolve the underlying issue of bladder distension, which compromises uterine hemostasis and must be addressed immediately.
Choice D rationale
While the health care provider must be informed of abnormal findings, contacting them is not the first action when a correctable physiological cause is highly suspected. The nurse should first attempt the least invasive intervention, which is addressing the likely full bladder, a common cause of this finding, and then reassess before escalating care. —.
Correct Answer is B
Explanation
Choice A rationale
Exclusively breastfeeding from the unaffected breast will lead to stasis of milk in the infected right breast, which is contraindicated in mastitis management. Milk stasis provides an excellent medium for bacterial growth and exacerbates the inflammation and pain associated with the infection, hindering resolution. Continued emptying of the affected breast is crucial to clear the infection and improve lymphatic and venous drainage, thus alleviating symptoms.
Choice B rationale
Massage helps to break up clogged milk ducts and move the milk toward the nipple, promoting more complete breast emptying. Hand expression further aids in draining the affected area and relieving engorgement, which reduces pressure and discomfort. Efficient milk removal is the most critical intervention to resolve milk stasis and prevent the progression of the infection and potential abscess formation.
Choice C rationale
Applying cold compresses typically acts as an analgesic and anti-inflammatory measure by causing vasoconstriction, thereby reducing edema and pain after a feeding. However, applying cold before a feeding can inhibit the let-down reflex (milk ejection reflex), making it harder for the infant to drain the breast effectively, which is counterproductive.
Choice D rationale
Discontinuing breastfeeding from the affected breast would lead to significant milk stasis, which is a primary predisposing factor and complication of mastitis. The stasis would worsen the inflammation and provide a favorable environment for bacteria to multiply. The recommendation is to continue breastfeeding (or pumping) frequently to ensure adequate drainage and expedite recovery, often with the guidance of a healthcare professional. —.
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