Nokea
A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: The correct answer is C. Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes. Vitamin K is essential for blood clotting, and newborns have lower levels at birth. Without enough vitamin K, newborns are at risk of bleeding issues. Giving them a vitamin K injection helps prevent potential bleeding disorders.
Choice A is incorrect because vitamin K is not given for digestion or fat absorption. Choice B is incorrect as erythromycin ointment is used for preventing eye infections, not related to vitamin K injections. Choice D is incorrect as vitamin K does not substitute for vitamin C, and it is not primarily for strengthening the immune system.
You may also like to solve these questions
As the infant nursery nurse, you are assisting with a
- A. Assess the fetal station delivery. After the initial assessment of the baby,
- B. Assess for rupture of the fetal membranes what is the next best action?
- C. Determine dilation of the cervix
- D. Give the infant a bath
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.
Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.
16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.
A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.