The mother of a full-term infant who is breastfeeding is concerned that her newborn infant may "turn yellow," as she has heard newborns sometimes do. Which information is correct for the nurse to provide this new mother?

Choice A rationale

While a newborn's liver is immature and can affect coagulation, phytonadione (vitamin K) is not administered to directly improve liver function. Its primary role is to provide the necessary co-factor for the synthesis of specific clotting factors, which are produced in the liver but are vitamin K dependent.

Choice B rationale

Newborns typically have insufficient dietary intake of vitamin K, but this is a secondary issue. The primary reason for administering the medication is the lack of vitamin K in the newborn's sterile gut, which is necessary for the production of clotting factors. The medication directly addresses the risk of bleeding.

Choice C rationale

Newborns have a sterile gut at birth and are unable to synthesize vitamin K, a fat-soluble vitamin essential for the hepatic synthesis of clotting factors II, VII, IX, and X. The administration of phytonadione prevents vitamin K deficiency bleeding, also known as hemorrhagic disease of the newborn. This statement shows correct understanding of the medication's purpose.

Choice D rationale

Phytonadione is not an immune system stimulant. Its function is confined to the coagulation cascade. The medication is specifically a vitamin that acts as a co-factor in the synthesis of prothrombin and other coagulation proteins. It does not play a direct role in stimulating or modulating the infant's immune response.

Choice A rationale

The immediate priority for a cyanotic infant who has regurgitated is to clear the airway. Cyanosis indicates inadequate oxygenation, which is often caused by an obstructed airway from the regurgitated material. Suctioning the oral and nasal passages removes the obstruction, allowing for effective breathing. This is the most critical first step to ensure the infant can ventilate and oxygenate. The body’s response to hypoxia is a cascade of detrimental physiological changes, making immediate airway clearance paramount.

Choice B rationale

Stimulating the infant to cry may be a secondary action, but it is ineffective if the airway is obstructed. A baby cannot take a deep breath to cry effectively if the airway is blocked. Furthermore, attempting to stimulate crying without clearing the obstruction could potentially draw the regurgitated material deeper into the respiratory tract, worsening the situation and increasing the risk of aspiration pneumonia. Airway clearance is the priority before any other intervention.

Choice C rationale

Giving oxygen by positive pressure is inappropriate as a first step. Positive pressure ventilation against an obstructed airway can force the regurgitated material deeper into the lungs, leading to aspiration and significant respiratory compromise. This action should only be taken after the airway has been successfully cleared by suctioning. Applying positive pressure ventilation without a clear airway is dangerous and could be life-threatening for the infant.

Choice D rationale

Turning the infant onto the right side is a measure to facilitate gastric emptying and prevent aspiration, but it is not the most immediate action for an infant who is already cyanotic. The cyanosis indicates an acute and urgent problem with oxygenation that requires immediate airway clearance. While positioning is a good preventive measure, it does not solve the immediate crisis of a blocked airway. Airway, breathing, and circulation (ABC) takes precedence over all other interventions.