Nokea
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
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A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching?
- A. I can use a hair dryer on the reddened skin to help with the drying.
- B. I can use powder after diaper changes to absorb excess moisture.
- C. I can use cloth diapers with rubber outer pants until the rash clears.
- D. I can keep the diaper off to expose the skin to air.
Correct Answer: D
Rationale: Exposing the skin to air helps prevent irritation and promotes healing.
A nurse is reviewing discharge instructions with the parent of an infant who has acute laryngotracheobronchitis (croup).
- A. "I will give my child the corticosteroids prescribed by the doctor."'
- B. "I will clear the child's nasal passages with a bulb syringe to aid in breathing."'
- C. "I will place a dehumidifier in my child's room."'
- D. "I will encourage my child to take plenty of fluids over the next several days."'
Correct Answer: C
Rationale: The correct answer is C: "I will place a dehumidifier in my child's room."
Rationale:
1. Acute laryngotracheobronchitis (croup) is a condition that causes swelling in the upper airway, leading to breathing difficulties.
2. Placing a dehumidifier in the child's room can help maintain optimal humidity levels, which can soothe the inflamed airways and ease breathing.
3. Moist air from the dehumidifier can help reduce coughing and throat irritation, providing comfort to the child.
4. This intervention is specific to managing the symptoms of croup and can support the child's recovery.
Summary:
- Choice A: Corticosteroids are prescribed by the doctor for croup, but it is not the parent's responsibility to administer them.
- Choice B: Clearing nasal passages with a bulb syringe is not directly related to managing croup symptoms.
- Choice D: Encouraging fluids
At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?
- A. Fetal heart rate averaging 160 beats/min
- B. Irregular contractions every 15-20 minutes that last 30 seconds before stopping
- C. Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
- D. Ferning pattern of vaginal discharge under a microscope
Correct Answer: D
Rationale: The correct answer is D - Ferning pattern of vaginal discharge under a microscope. This finding indicates rupture of membranes which can lead to infection and necessitates immediate medical attention to prevent harm to the fetus and mother. A: Fetal heart rate of 160 bpm is within normal range. B: Irregular contractions every 15-20 minutes are not indicative of active labor. C: Maternal vital signs are within normal limits and do not pose an immediate threat.
A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant?
- A. It will cause the infant's blood sugar to fall.
- B. It will cause the infant's respiratory rate to decrease.
- C. It will cause the infant's heart rate to increase.
- D. It will cause the infant's movements to be hyperactive.
Correct Answer: B
Rationale: The correct answer is B: It will cause the infant's respiratory rate to decrease. Narcotic analgesics can cross the placenta and affect the baby. These medications can depress the respiratory drive of the newborn, leading to decreased respiratory rate. This effect is particularly pronounced if the narcotic is given shortly before delivery when the drug levels in the infant's system are highest. The other choices are incorrect because: A) Narcotics are not known to directly affect blood sugar levels in infants. C) Narcotics typically cause a decrease, rather than an increase, in heart rate. D) Narcotics are more likely to cause sedation and decreased movements rather than hyperactivity in newborns.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question helps differentiate true labor from false labor because the presence of bloody show or amniotic fluid suggests cervical changes associated with true labor. Bloody show indicates the shedding of the cervical mucus plug, and amniotic fluid leakage indicates rupture of membranes. This information helps confirm the progression of labor.
Choice A: "When did your contractions begin?" is a general question that does not specifically differentiate between true and false labor.
Choice C: "What happens to your contractions when you move about?" is more related to the management of labor rather than differentiating true labor from false labor.
Choice D: "Have you felt fetal movement over the last 24 hours?" is important for assessing fetal well-being but does not help in distinguishing true labor from false labor.