RN45 Vitamin K (Phytonadione) Maternal Newborn- CE

A student nurse is asking about a 3-day-old newborn's ability to produce vitamin K. By what age can healthy newborns produce their own vitamin K?

1 week Rationale: Healthy newborns can produce their own vitamin K by 7 days of life as a result of the introduction of bacteria with the first feeding. Vitamin K production starts before 2, 3, and 4 weeks.

When administering vitamin K, the nurse should avoid which action?

Administering vitamin K into the rectus femoris muscle Rationale: The rectus femoris muscle is closer to the femoral artery and vein than the vastus lateralis muscle and should not be used

A newborn has been diagnosed with early VKDB. Which medications are associated with this condition?

Anticoagulants Rationale: Vitamin K prophylaxis after delivery will not prevent early VKDB in the newborn. Maternal medications (e.g., anticoagulants, anticonvulsants, and antituberculosis drugs) are associated with early VKDB.

After the nurse administers an injection of vitamin K to a newborn, what is the most appropriate nursing action?

Applying pressure to the injection site with a gauze pad Rationale: Applying gentle pressure to the injection site helps prevent pain and trauma.

The nurse is preparing to administer an IM injection of vitamin K to a newborn. During the procedure, what is the most appropriate comfort measure for the newborn?

Asking the mother to breastfeed the newborn Rationale: Although the injection can be administered under a radiant warmer, the infant will receive greater comfort by being breastfed by the mother during the injection. Sucking is known to promote a newborns comfort.

A breastfeeding newborn shows signs of late-onset VKDB. Which bleeding site is at high risk in newborns with this condition?

Cranium Rationale: The incidence of intracranial hemorrhage is high with late-onset VKDB. Late-onset VKDB may occur when the infant is between 2 weeks and 6 months old. Other bleeding sites in late-onset VKDB include the stomach and intestines.

Which statement regarding the practice of giving newborns vitamin K immediately after birth is most accurate?

Newborn's GI systems are sterile, resulting in a lack of vitamin K production Rationale: Newborns are relatively deficient in vit K at birth, & because of their sterile gut, they cannot adequately produce it. VItamin K is necessary for the activation of clotting factors II, VII, IX, & X.

A 2-day-old newborn begins bleeding profusely from the umbilical cord site. The nurse applies pressure to the site and, upon reviewing the newborn's record, learns that the newborn did not receive vitamin K at birth because the mother refused. Which risk factor associated with classic-onset VKDB might the nurse find in this newborn's record?

Nutrition obtained via breastfeeding Rationale: BBacteria introduced into the GI tract during feeding helps initiate the production of vitamin K; however, classic-onset VKDB occurs because of the low vitamin K content of breast milk

A nurse who is new to the unit is about to administer vitamin K via IM injection to a newborn and is not sure which site to choose for injection. Which site would the senior nurse advise the new nurse to use?

Vastus lateralis muscle Rationale: This is the preferred site for an IM injection in the newborn.

A healthy newborn is born at 39 weeks' gestation. The nurse notices bleeding from the umbilical cord site. When would the nurse expect to see signs of early VKDB?

Within the first 24 hours Rationale: Early VKDB normally occurs within the first 24 hours. Typically, it occurs as a result of maternal exposure to medications that interfere with how the body uses vitamin K, resulting in anticoagulation