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A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A, to administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves or blood vessels. This site is typically used for vaccines in infants to ensure proper absorption and minimize discomfort. Option B is incorrect as massaging the site can lead to discomfort or tissue damage. Option C is incorrect as inserting the needle at a 45° angle is not necessary for intramuscular injections in newborns. Option D is incorrect as a smaller gauge needle is usually recommended for newborns to reduce pain and tissue trauma.
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Which of the following is a potential barrier to evidence-based practice in maternal and newborn healthcare?
- A. Lack of access to up-to-date research
- B. Resistance to change
- C. Limited resources
- D. All of the above
Correct Answer: D
Rationale: All the options listed (lack of access to research resistance to change and limited resources) are common barriers to implementing evidence-based practice in healthcare settings. These factors can hinder the adoption of new practices and the improvement of care quality.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is crucial in preventing compression and desiccation of the umbilical cord, which could lead to decreased blood flow and oxygen delivery to the fetus. By covering the cord, the nurse can protect it from further damage while waiting for emergency intervention. Performing a vaginal examination (choice A) could worsen the situation by causing more pressure on the cord. Administering oxygen (choice C) may be important later but is not the immediate priority. Initiating IV fluids (choice D) is not the most urgent action in this scenario.
Which of the following is a potential complication of a preterm infant?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Hyperbilirubinemia
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Preterm infants are at increased risk for various complications due to their immature organ systems. Hypoglycemia can occur due to limited glycogen stores. Respiratory distress syndrome results from insufficient surfactant production in underdeveloped lungs. Hyperbilirubinemia is common as the liver may not efficiently process bilirubin. Choosing D is correct as all these complications can affect preterm infants. Options A, B, and C are incorrect as they individually address only one potential complication, whereas D encompasses all possibilities.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The priority intervention is to begin FHR (fetal heart rate) monitoring to ensure the fetus is not in distress after the rupture of membranes. This is critical for fetal well-being.