The nurse administers vitamin K to the newborn for what reason?
Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
The supply of vitamin K is inadequate for at least 12 months, and the newborn musti supplemented throughout infancy.
Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
The Correct Answer is A
A) Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract:
Newborns are born with a sterile gastrointestinal tract, meaning they do not yet have the intestinal bacteria necessary to synthesize vitamin K. Vitamin K is essential for the activation of clotting factors, and without sufficient vitamin K, newborns are at risk for bleeding disorders, particularly a condition known as vitamin K deficiency bleeding (VKDB). Administering vitamin K by injection shortly after birth ensures the baby has adequate levels to prevent bleeding.
B) Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection:
This statement is incorrect. Vitamin K does not prevent the synthesis of prothrombin; rather, it is essential for the liver to synthesize clotting factors, including prothrombin. The injection of vitamin K in newborns is necessary to provide adequate levels of vitamin K to support proper blood clotting, as newborns cannot produce enough on their own at birth due to the absence of gut bacteria that normally produce it.
C) The supply of vitamin K is inadequate for at least 12 months, and the newborn must be supplemented throughout infancy:
While it is true that newborns have a limited supply of vitamin K at birth, this deficiency is typically addressed with a single injection given shortly after birth. Supplementing vitamin K throughout infancy is generally not required, as the infant's gastrointestinal tract will start to develop the necessary bacteria to synthesize vitamin K within the first few weeks to months of life. The first dose of vitamin K prevents bleeding disorders, and in most cases, additional supplementation is not necessary.
D) Most mothers have a diet deficient in vitamin K, which results in the infant being deficient:
While maternal diet does play a role in the newborn's initial vitamin K levels, it is not the primary reason for the deficiency. Vitamin K deficiency in newborns is primarily due to the lack of gut bacteria necessary to produce it, rather than maternal diet. The practice of administering vitamin K to all newborns ensures that they receive adequate levels to prevent bleeding, regardless of maternal dietary intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) The neonate with respirations of 78 and a heart rate of 176:
This is the most concerning finding and requires immediate evaluation. Normal respiratory rate for a newborn is typically between 30 and 60 breaths per minute, so a rate of 78 breaths per minute is significantly elevated, indicating potential respiratory distress. Additionally, a heart rate of 176 beats per minute, while somewhat elevated, could indicate tachycardia, especially if the baby is experiencing distress or inadequate oxygenation. This combination of abnormal vital signs may point to respiratory or cardiovascular compromise, such as respiratory distress syndrome or other neonatal respiratory issues, which requires immediate evaluation and intervention.
B) The neonate with a temperature of 99.1°F and a weight of 3000 grams:
This neonate’s temperature is within the normal range (97.7°F to 99.5°F), and a weight of 3000 grams is also considered appropriate for a full-term newborn. These findings do not raise any immediate concerns, and no further action is necessary based on these observations alone.
C) The neonate with raised white specks on the gums:
Raised white specks or nodules on the gums are often a normal finding in newborns and are called Epstein pearls. These are benign cystic formations that do not require treatment. They are not a cause for concern and are common in newborns, usually disappearing on their own within a few weeks.
D) The neonate with white spots on the bridge of the nose:
White spots on the nose are likely to be Milia, which are small, benign cysts commonly seen on the face of newborns, particularly on the nose, cheeks, and chin. Milia are harmless and typically resolve without treatment within a few weeks. There is no need for concern in this case.
Correct Answer is C
Explanation
A) Don’t concern yourself with it and agree with the family that it is cute:
While it may seem cute, it is important to recognize that abnormal sounds like grunting in a newborn can be a sign of respiratory distress. Grunting is a compensatory mechanism used by the infant to help keep the alveoli open during exhalation, indicating that the baby may be struggling to maintain adequate oxygenation. Ignoring these signs could delay necessary interventions.
B) Begin Resuscitation on the infant:
Resuscitation would be indicated if the baby were showing signs of severe respiratory distress, such as a significant drop in heart rate, poor oxygenation, or altered mental status. However, a cooing sound that is consistent with the baby’s respiratory effort does not immediately warrant resuscitation. The correct approach is to assess the baby further to determine if the issue is respiratory distress or something less severe.
C) Realize that the baby is grunting and continue to assess infant's respiratory status:
Grunting in a newborn can be a sign of respiratory distress. It is important to differentiate between normal sounds (like cooing) and abnormal sounds (like grunting) that might indicate the infant is working harder to breathe. In this scenario, the nurse should continue to assess the baby’s respiratory rate, effort, oxygen saturation, and overall condition. If the grunting persists or worsens, further intervention may be required.
D) Put the baby on Nasal Cannula at 100%:
While supplemental oxygen may be necessary if the infant is in respiratory distress, placing the baby on nasal cannula at 100% oxygen without further assessment is premature. First, the nurse should assess the baby's overall respiratory status, including oxygen saturation, effort, and any signs of distress before deciding if oxygen therapy is needed.
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