The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales?
Select one:
Vitamin K will increase erythropoiesis.
Vitamin K will enhance bilirubin breakdown.
Vitamin K will stop Rh sensitization.
Vitamin K will promote blood clotting ability. Vitamin K will promote blood clotting ability.
The Correct Answer is D
Choice A Reason: Vitamin K will increase erythropoiesis. This is an incorrect statement that confuses vitamin K with erythropoietin. Erythropoietin is a hormone that stimulates red blood cell production in the bone marrow. Vitamin K does not affect erythropoiesis.
Choice B Reason: Vitamin K will enhance bilirubin breakdown. This is an incorrect statement that confuses vitamin K with phototherapy. Phototherapy is a treatment that exposes the newborn's skin to light, which converts bilirubin into water-soluble forms that can be excreted by the liver and kidneys. Bilirubin is a yellow pigment that results from the breakdown of red blood cells. High levels of bilirubin can cause jaundice and brain damage in newborns. Vitamin K does not affect bilirubin metabolism.
Choice C Reason: Vitamin K will stop Rh sensitization. This is an incorrect statement that confuses vitamin K with Rh immune globulin. Rh immune globulin is an injection given to Rh-negative mothers who deliver Rh-positive babies, to prevent them from developing antibodies against Rh-positive blood cells in future pregnancies. Rh sensitization is a condition where the mother's immune system atacks the baby's blood cells, causing hemolytic disease of the newborn. Vitamin K does not affect Rh sensitization.
Choice D Reason: Vitamin K will promote blood clotting ability. This is a correct statement that explains the rationale for administering vitamin K as prophylaxis to newborns. Vitamin K is essential for the synthesis of clotting factors in the liver. Newborns have low levels of vitamin K at birth due to poor placental transfer and lack of intestinal bacteria that produce vitamin K. Therefore, they are at risk of bleeding disorders such as hemorrhagic disease of the newborn.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Maintain the client on strict bedrest. This is an inappropriate action that may worsen the client's condition and increase her isolation and depression. Postpartum psychosis requires prompt psychiatric treatment with medication and psychotherapy, not bedrest.
Choice B Reason: Carefully monitor intake and output. This is an irrelevant action that has no direct relation to postpartum psychosis or its management. Monitoring intake and output may be indicated for other postpartum complications such as hemorrhage, infection, or preeclampsia.
Choice C Reason: Restrict visitation of the client's partner. This is an unnecessary action that may deprive the client of social support and emotional comfort. The partner may be an important source of help and information for the client and the health care team. The partner should be involved in the client's care and education, unless there are signs of abuse or violence.
Choice D Reason: Closely supervise all infant care and interaction. This is because postpartum psychosis is a severe mental disorder that occurs in some women after childbirth, which can cause delusions, hallucinations, paranoia, mood swings, confusion, and suicidal or homicidal thoughts. Postpartum psychosis can pose a danger to both the mother and the infant, as the mother may harm herself or the infant due to distorted perceptions or impulses. The nurse should closely supervise all infant care and interaction to ensure safety and prevent injury.

Correct Answer is C
Explanation
Choice A Reason: IgG. This is an incorrect answer that refers to a different type of antibody that is not abundant in breast milk. IgG is a type of antibody that provides systemic immunity against various antigens. IgG is found in low concentrations in breast milk, as it does not cross the mammary epithelium easily. IgG can protect the infant from some infections, but it is mainly transferred from the mother to the fetus through the placenta during pregnancy.
Choice B Reason: IgE. This is an incorrect answer that refers to a different type of antibody that is not relevant to breast milk. IgE is a type of antibody that mediates allergic reactions and parasitic infections. IgE is found in very low concentrations in breast milk, as it does not have a significant role in mucosal immunity. IgE can trigger mast cells and basophils to release histamine and other inflammatory mediators, which can cause symptoms such as itching, swelling, or bronchoconstriction.
Choice C Reason: IgA. This is because IgA is a type of antibody that protects mucosal surfaces from pathogens and toxins. IgA is found in high concentrations in breast milk, especially in colostrum (the first milk produced after delivery). IgA can bind to bacteria and viruses in the infant's gastrointestinal tract and prevent them from ataching to the intestinal wall or crossing into the bloodstream. IgA can also enhance the infant's immune system by stimulating lymphoid tissue development and modulating inflammatory responses.
Choice D Reason: IgM. This is an incorrect answer that refers to a different type of antibody that is not abundant in breast milk. IgM is a type of antibody that activates complement system and agglutinates antigens. IgM is found in low concentrations in breast milk, as it does not cross the mammary epithelium easily due to its large size. IgM can protect the infant from some infections, but it is mainly produced by the infant's own immune system in response to exposure to antigens.
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