A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Ask the client to empty their bladder.

This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.

Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.

Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.

Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.

The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.

Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.

Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.

Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.