A nurse is preparing to administer an IM injection for an infant. Which of the following actions should the nurse take?
Administer the medication into the vastus lateralis muscle.
Administer the medication with a 20-gauge needle.
Administer the medication into the deltoid muscle.
Administer the medication over 2 min.
The Correct Answer is A
Rationale:
A. Administer the medication into the vastus lateralis muscle: The vastus lateralis is the preferred site for intramuscular injections in infants because it is well-developed and free of major nerves and blood vessels. This site allows for safe and effective absorption of the medication.
B. Administer the medication with a 20-gauge needle: A 20-gauge needle is too large for infants and can cause unnecessary tissue trauma. A smaller gauge, typically 22–25, is appropriate for IM injections in infants to minimize pain and tissue damage.
C. Administer the medication into the deltoid muscle: The deltoid muscle is underdeveloped in infants, making it unsuitable for IM injections due to limited muscle mass and risk of injury to underlying structures. It is generally used only in older children or adults.
D. Administer the medication over 2 min: IM injections are typically administered at a moderate pace, but a 2-minute administration is unnecessarily slow for infants. Proper technique involves steady, controlled injection without causing excessive discomfort.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Decide which clients should be transported for a higher level of care: Determining transport priorities is usually the responsibility of the incident command or emergency response team, not individual unit nurses. Unit nurses provide patient assessments and recommendations but do not independently make these critical decisions.
B. Act as a spokesperson to provide information to the media: Communication with the media is handled by designated hospital public relations or administration personnel to ensure consistent and accurate information. Unit nurses are not responsible for media interactions during a disaster.
C. Recommend to the provider a list of clients for early discharge: Unit nurses are familiar with clients’ conditions, stability, and care needs, making them well-suited to recommend which clients can be safely discharged early. This helps prioritize resources and bed availability during a disaster while maintaining patient safety.
D. Determine the need for additional providers: Assessing staffing needs is the responsibility of the nurse manager or disaster coordinator. Unit nurses provide information about patient care demands but do not make staffing deployment decisions during an emergency.
Correct Answer is B
Explanation
Rationale:
A. Palpate the uterus for contractions: Assessing uterine activity is important after a seizure to monitor for labor or fetal compromise, but it does not address the immediate risk of maternal hypoxia following a seizure. This assessment can be performed after ensuring adequate oxygenation.
B. Administer oxygen 10 L/min via nonrebreather mask: After a seizure, the client is at risk for hypoxia due to apnea or increased oxygen demand. Administering high-flow oxygen is the priority action to restore oxygenation, support maternal and fetal perfusion, and prevent further complications.
C. Observe for post-convulsion incontinence: Monitoring for incontinence helps assess seizure severity and patient safety, but it does not immediately correct the critical issue of hypoxia. Observation is secondary to interventions that maintain airway and oxygenation.
D. Provide a quiet environment: Reducing stimuli can help prevent additional seizures or stress, but it is not the first priority after a seizure. Ensuring airway patency and oxygen delivery takes precedence over environmental modifications.
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