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: Partial placenta previa is a condition where the placenta partially covers the cervix. It usually does not resolve and may cause bleeding and complications during labor and delivery.
Choice B Reason: Complete placenta previa is a condition where the placenta completely covers the cervix. It is a serious condition that requires cesarean delivery and may cause life-threatening hemorrhage.
Choice C Reason: Marginal placenta previa is a condition where the edge of the placenta reaches the margin of the cervix. It may also cause bleeding and complications during labor and delivery.
Choice D Reason: Low-lying placenta previa is a condition where the placenta is near the cervix, but not covering it. It may resolve spontaneously as the uterus grows and the placenta moves upward.
Correct Answer is C
Explanation
Choice A Reason: Manifestations of uteroplacental insufficiency. This is an incorrect answer that describes a different condition that affects the fetus, not the mother. Uteroplacental insufficiency is a condition where the placenta fails to deliver adequate oxygen and nutrients to the fetus, which can result in fetal growth restriction, distress, or demise. Uteroplacental insufficiency does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice B Reason: Manifestations of prolapsed cord. This is an incorrect answer that refers to another condition that affects the fetus, not the mother. Prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen flow to the fetus. Prolapsed cord does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice C Reason: Manifestations of anaphylactoid syndrome of pregnancy. This is because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and fatal condition where amniotic fluid enters into the maternal bloodstream and causes an allergic reaction, which can lead to respiratory failure, cardiac arrest, coagulopathy, and coma. Anaphylactoid syndrome of pregnancy can occur during or after labor and delivery, especially in cases of NSVD, multiparity, advanced maternal age, or placental abruption.
Choice D Reason: Manifestations of an acute asthmatic episode. This is an incorrect answer that assumes that the mother has a history of asthma or an allergic trigger. Asthma is a chronic inflammatory disorder of the airways that causes wheezing, coughing, chest tightness, and dyspnea. Asthma can be exacerbated by pregnancy or labor, but it is not a common cause of sudden onset respiratory distress in the postpartum period.
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