A nurse is preparing to administer vitamin K intramuscularly to a newborn. Which of the following muscles should the nurse use for the injection?

Choice A rationale

While involving the family in the care of an older adult client is important, calling the family to make arrangements for someone to sit with the client is not the immediate action the nurse should take. The nurse’s first responsibility is to ensure the client’s safety and well-being.
Choice B rationale
Obtaining a prescription for medication to sedate the client is not the immediate action the nurse should take. Sedating the client does not address the immediate concern of potential injury.
Choice C rationale
The nurse should first check the client for injuries. This is the immediate action because the client may have sustained injuries from the fall. The nurse should perform a thorough assessment to determine the extent of any injuries and provide appropriate care.
Choice D rationale
Assisting the client back into bed and applying restraints is not the immediate action the nurse should take. Restraints should be used as a last resort and only if less restrictive measures have been ineffective. Furthermore, restraints require a physician’s order.

Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale

Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.