Page 858 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Maternity: Newborn
Health Problem: Newborn: Newborn of a Diabetic Mother
Priority Concepts: Clinical Judgment; Glucose Regulation
Reference: McKinney et al. (2018), pp. 652-653.

282. Answer: 3

Rationale: Precautions to prevent infant abduction include placing a newborn’s
crib away from the door, transporting a newborn only in the crib and never carrying
the newborn, expecting health care personnel to wear identification that is easily
visible at all times, and asking the nurse to attend to the newborn if the mother is
napping and no family member is available to watch the newborn (the newborn is
never left unattended). If the mother states that she will ask the nurse to watch the
newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 4
are incorrect and indicate that the mother needs further teaching.
Test-Taking Strategy: Focus on the subject, that the client understands
precautions to prevent infant abduction. Read each option carefully and select the
option that provides protection to the infant. This will direct you to the correct
option.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Maternity: Newborn
Health Problem: N/A
Priority Concepts: Client Education; Safety
Reference: McKinney et al. (2018), pp. 469-470.

283. Answer: 4

Rationale: Phytonadione is necessary for the body to synthesize coagulation
factors. It is administered to the newborn to prevent bleeding disorders. It also
promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are
vitamin K–deficient because the bowel does not have the bacteria necessary to
synthesize fat-soluble vitamin K. The normal flora in the intestinal tract produces
vitamin K. The newborn’s bowel does not support the normal production of vitamin
K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as
food is ingested. Vitamin K does not promote the development of immunity or
prevent the infant from becoming jaundiced.
Test-Taking Strategy: Note the strategic word, best. Because immunity and
jaundice are not related to the action of vitamin K, eliminate options 1 and 2. From
the remaining options, recall the action of vitamin K to direct you to the correct
option. Remember that vitamin K does not promote the growth of bacteria but is
administered to prevent bleeding.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity

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