The nurse has a routine prescription to administer an injection ...

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The nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Before giving the medication, the nurse explains to the client that this medication will:
 
  1. Prevent clotting abnormalities in the newborn.
  2. Stimulate the liver to produce vitamin K.
  3. Prevent vitamin deficiency of fat-soluble vitamins.
  4. Supplement the infant, because breast milk and formula are low in vitamin K.

Question 2

The nurse provides instructions to the mother of a child with sickle cell disease. Which of the following statements, if made by the mother, indicates a need for further education?
 
  1. I need to be sure that my child has adequate rest periods.
  2. I need to take my child's temperature and watch for a fever.
  3. I need to encourage my child to drink large amounts of fluids.
  4. I need to make sure that my child spends some time in the sun to help prevent a sickle cell crisis.

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Answer to Question 1

1

Rationale: Vitamin K is given to the newborn to prevent clotting abnormalities. Vitamin K is usually produced by bacteria in the gastrointestinal tract, which is sterile in the newborn. The other options are incorrect reasons for administering this medication to a newborn.

Answer to Question 2

4

Rationale: The nurse should instruct the mother to encourage fluid intake 1.5 to 2 times the daily requirements. Adequate rest periods should be provided, and the child should not be exposed to cold or heat stress. The mother should be taught how to take the child's body temperature and how to use a thermometer properly. Sources of infection should be avoided, as should prolonged exposure to the sun.

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