A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

Choice A rationale:

The nurse should monitor the urinary output of the client as it can be an important indicator of hydration and renal function. However, in this specific scenario, the administration of oxytocin via IV infusion after a vaginal delivery requires a different focus for evaluating medication effectiveness.

Choice B rationale:

The nurse should primarily assess the fundal consistency to evaluate the effectiveness of oxytocin. Oxytocin is often administered after childbirth to promote uterine contractions and prevent postpartum hemorrhage. Checking the fundal consistency helps determine if the uterus is contracting appropriately. A firm fundus indicates effective contractions, which are essential for controlling bleeding and preventing complications.

Choice C rationale:

Monitoring the pulse rate is a vital aspect of patient care, but it may not be the most relevant parameter to evaluate the effectiveness of oxytocin. Pulse rate can give information about the client's cardiovascular status and general well-being, but it does not directly assess the medication's impact on uterine contractions.

Choice D rationale:

Similarly, keeping an eye on blood pressure is crucial for patient safety and detecting potential issues like hypertension. However, it is not the primary parameter for evaluating the effectiveness of oxytocin. Blood pressure monitoring is essential for overall health assessment but does not directly relate to the medication's intended effect.

The correct answer is choice C. Assist the client to breathe into a paper bag.

Choice A rationale:

Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.

Choice B rationale:

Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.

Choice C rationale:

Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.

Choice D rationale:

Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.