Nokea
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
- A. Dorsogluteal
- B. Vastus lateralis
- C. Deltoid
- D. Ventrogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice D) can be used in older infants but is not the preferred site for newborns.
You may also like to solve these questions
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing preterm labor at 26 weeks of gestation.
- B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.
- C. A client who has a post-term pregnancy at 42 weeks of gestation.
- D. A client who is experiencing fetal death at 32 weeks of gestation.
Correct Answer: A
Rationale: The correct answer is A: A client who is experiencing preterm labor at 26 weeks of gestation. Tocolytic therapy is used to inhibit uterine contractions and delay preterm labor. Administering tocolytic therapy to a client experiencing preterm labor at 26 weeks helps prevent premature birth and its associated complications. Choices B, C, and D are incorrect because Braxton-Hicks contractions at 36 weeks, post-term pregnancy at 42 weeks, and fetal death at 32 weeks do not warrant tocolytic therapy as they are not indicative of preterm labor.
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Notify the client’s provider.
- B. Increase the frequency of fundal massage.
- C. Encourage the client to empty her bladder.
- D. Document the findings and continue to monitor the client.
Correct Answer: D
Rationale: The correct answer is D: Document the findings and continue to monitor the client. At 1 hour postpartum, it is normal to have lochia rubra and small clots as the uterus is contracting to expel the placenta fragments. The firm, midline fundus at the umbilicus indicates proper involution. There is no indication of excessive bleeding or abnormal fundal position, so there is no immediate concern. Therefore, the nurse should document the findings to establish a baseline and continue to monitor the client for any changes.
Choice A is incorrect because there is no indication to notify the provider at this time. Choice B is unnecessary as the fundus is already firm. Choice C is not the priority as the fundus position and consistency are appropriate. Monitoring and documentation are essential in this situation to detect any deviations from normal postpartum progress.
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care after birth?
- A. Observe for meconium in respiratory secretions.
- B. Monitor for hyperthermia.
- C. Identify manifestations of anemia.
- D. Monitor for hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Observe for meconium in respiratory secretions. This is important because infants who are small for gestational age (SGA) are at increased risk for meconium aspiration syndrome due to their underdeveloped lungs. Meconium in respiratory secretions can lead to respiratory distress and requires immediate intervention.
Choice B, monitoring for hyperthermia, is incorrect as it is not specifically related to SGA infants. Choice C, identifying manifestations of anemia, is also incorrect as SGA infants may have normal hematologic parameters. Choice D, monitoring for hyperglycemia, is not directly associated with SGA infants and is more relevant to infants of diabetic mothers.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
- A. Place a finger at the base of the newborn’s toes.
- B. Turn the newborn’s head quickly to one side.
- C. Hold the newborn vertically allowing one foot to touch the table surface.
- D. Perform a sharp hand clap near the infant.
Correct Answer: D
Rationale: The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.