The nurse is about to administer phytonadione to a newborn.
Which statement by the parents shows they understand why this medication is being given?
It stimulates the immune system.
It aids an immature liver.
It prevents hemorrhagic disorders.
It compensates for insufficient dietary intake.
The Correct Answer is C
Choice A rationale
While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.
Choice B rationale
Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.
Choice C rationale
This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.
Choice D rationale
While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.
Choice B rationale
Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.
Choice C rationale
While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.
Choice D rationale
A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.
Correct Answer is C
Explanation
Choice A rationale
While monitoring the variability of the fetal heart rate is important during labor, it is not the most crucial assessment after administering epidural anesthesia15.
Choice B rationale
Assessing the level of pain sensation is important to ensure the effectiveness of the epidural anesthesia. However, it is not the most crucial assessment15.
Choice C rationale
Checking the maternal blood pressure is the most crucial assessment after administering epidural anesthesia15. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.
Choice D rationale
Determining the station of the presenting part is important during labor, but it is not the most crucial assessment after administering epidural anesthesia15.
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