Nokea
Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?
- A. Rectus femoris muscle
- B. Deltoid muscle
- C. Gluteal muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.
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A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?
- A. Notifying the healthcare provider
- B. Stopping the oxytocin infusion
- C. Checking the woman's blood pressure and pulse
- D. Increasing the intravenous (IV) rate of the nonadditive solution
Correct Answer: B
Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.
What is a chemical reaction between drugs before their administration or absorption known as?
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct Answer: A
Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.
A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?
- A. Pinto beans
- B. Lettuce
- C. Oranges
- D. Broccoli
Correct Answer: A
Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving. Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.
A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
- A. By checking the client's urine for blood
- B. By checking the client's stool for blood
- C. By checking the client's urine for a decrease in output
- D. By checking the client's bowel movements for diarrhea
Correct Answer: B
Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
Which of the following vaccines is not part of the regular schedule of immunizations for children?
- A. DTaP
- B. MMR
- C. Hib
- D. hepatitis A
Correct Answer: D
Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.