A nurse is preparing to administer vitamin K 1 mg IM to a newborn. Available is vitamin K injection 1 mg/0.5 mL. How many mL should the nurse administer per dose?
Choice A: 0.25 mL
Choice B: 0.5 mL
Choice C: 0.75 mL
Choice D: 1 mL
The Correct Answer is B
Choice A rationale:
0.25 mL - The nurse should not administer 0.25 mL because the available concentration of vitamin K injection is 1 mg/0.5 mL. To achieve the prescribed dose of 1 mg, administering only 0.25 mL would be insufficient.
Choice B rationale:
0.5 mL - This is the correct choice. The nurse should administer 0.5 mL of the vitamin K injection to deliver 1 mg of vitamin K, as the concentration of the injection is 1 mg/0.5 mL. By giving the full 0.5 mL, the newborn will receive the appropriate 1 mg dose.
Choice C rationale:
0.75 mL - Administering 0.75 mL would be excessive for the prescribed 1 mg dose of vitamin K. It is unnecessary to give a higher volume than required, as it could lead to potential adverse effects or wastage.
Choice D rationale:
1 mL - Similarly, administering the entire 1 mL of the vitamin K injection would result in doubling the prescribed dose, leading to potential overdose and adverse reactions. The nurse should avoid administering more than the necessary 0.5 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labor, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labor has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
Choice B rationale:
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
Choice C rationale:
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.
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