A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?
Deltoid.
Dorsogluteal.
Ventrogluteal.
Vastus lateralis.
The Correct Answer is D
The correct answer is choice d. Vastus lateralis.
Choice A rationale:
The deltoid muscle is not typically used for newborn injections because it is too small and underdeveloped, making it an inappropriate site for intramuscular injections in this age group.
Choice B rationale:
The dorsogluteal muscle is also not recommended for newborns due to the risk of injury to the sciatic nerve and the muscle’s underdevelopment.
Choice C rationale:
The ventrogluteal muscle, while a good site for older children and adults, is not commonly used for newborns because it is not as easily accessible and developed as the vastus lateralis.
Choice D rationale:
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. It is well-developed and provides a large muscle mass, making it the safest and most effective site for administering vitamin K.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, Maternal hypertension.
Choice A rationale:
Maternal hypertension is widely recognized as the most common risk factor for placental abruption. High blood pressure can cause the placenta to detach from the uterine wall, leading to abruption. In summary, while all the listed factors can contribute to the risk of placental abruption, maternal hypertension stands out as the most common cause, supported by multiple health sources. It’s important for nurses to recognize and manage hypertension in pregnant clients to minimize the risk of this serious complication.
Choice B rationale:
While maternal cocaine use is a significant risk factor for placental abruption due to its vasoconstrictive effects, which can compromise the placental blood flow, it is not as common as maternal hypertension.
Choice C rationale:
Maternal cigarette smoking is also a risk factor for placental abruption. Smoking can lead to a variety of complications in pregnancy, including placental problems, but again, it is less common than hypertension as a cause for abruption.
Choice D rationale:
Maternal battering can lead to trauma which may result in placental abruption. However, it is not considered the most common risk factor when compared to maternal hypertension.
Correct Answer is C
Explanation
Choice A reason:
Blood pressure. The nurse does not need to report the blood pressure because it is not mentioned in the given information that there is any abnormality or concern related to the client's blood pressure. Therefore, it is not a priority finding to report.
Choice B reason:
Cerebral manifestations. There is no mention of cerebral manifestations in the nurse's notes. Since there are no reported neurological symptoms or abnormalities, the nurse does not need to report cerebral manifestations to the provider.
Choice C reason:
Fetal heart rate. The nurse should report the fetal heart rate to the provider because it is an essential parameter to monitor during prenatal care. A normal fetal heart rate ranges from 110 to 160 beats per minute, and in this case, the fetal heart rate is 158/min, which falls within the normal range. However, it is still necessary to inform the provider about this vital sign for documentation and reassurance.
Choice D reason:
Respiratory rate. The respiratory rate is not mentioned in the nurse's notes, and there are no indications of any respiratory issues or concerns. Therefore, it is not necessary to report the respiratory rate to the provider based on the information provided.
Choice E reason:
Deep tendon reflexes. The nurse notes that the patellar reflex is 3+ and clonus is negative. These findings are within the normal range and do not require reporting to the provider.
Choice F reason:
Gastrointestinal assessment findings. The nurse's notes do not mention any abnormal gastrointestinal assessment findings. Since there are no indications of gastrointestinal issues, the nurse does not need to report any gastrointestinal findings to the provider.
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