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A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its large muscle mass, minimal nerves and blood vessels, and reduced risk of hitting bone. It is located on the lateral aspect of the thigh and is easily accessible for injections. This site also allows for proper absorption of the medication. The other options are not ideal for newborns: B: Dorsogluteal is not recommended due to the risk of damaging the sciatic nerve, C: Deltoid is typically used for older children and adults, and D: Rectus femoris is not a common site for IM injections in newborns.
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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A: Frequent vomiting with weight loss of 3 lb in 1 week. This finding is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances, posing a risk to both the mother and fetus. The weight loss is significant and needs immediate attention from the provider to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are often due to increased blood volume and hormone changes during pregnancy and are not considered a serious issue unless they are severe or frequent.
D: Increased vaginal discharge is a common symptom of pregnancy and is usually not a cause for alarm unless accompanied by other symptoms like itching or a foul odor.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Positioning the client supine with knees flexed and a rolled towel under one hip (B) helps relax the abdomen and facilitate palpation. Palpating the fetal part in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) aids in assessing the fetal lie and engagement. Choices E, F, and G are not relevant to the correct sequence of Leopold maneuvers.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (A) delays immediate intervention. Administering simethicone (B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (D) does not address the underlying issue of uterine atony.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: The correct answer is D: To facilitate bonding between the newborn and parent. Applying the ointment immediately after birth may interfere with the crucial bonding process between the newborn and the parent. It is important for the parent to have uninterrupted skin-to-skin contact and establish a strong emotional connection with the newborn during the first moments after birth. This bonding time is essential for the newborn's emotional well-being and can have long-lasting positive effects on their development. Delaying the instillation of the ointment allows for this important bonding process to occur naturally.
Choice A is incorrect because early identification of infection is crucial and should not be delayed. Choice B is unrelated to the instillation of ointment. Choice C is also unrelated, as the mode of delivery does not affect the timing of ointment instillation.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.