Nursing Elites

1. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

• A. Vastus lateralis
• B. Ventrogluteal
• C. Dorsogluteal
• D. Deltoid

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

2. A healthcare provider is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the provider include in the teaching? (Select all that apply)

• A. Weight fluctuations can occur.
• B. Irregular vaginal spotting can occur.
• C. You should increase your intake of calcium.
• D. All of the above

Correct answer: D

Rationale: When educating a client about medroxyprogesterone, it is important to include information about potential side effects and recommendations. Weight fluctuations and irregular vaginal spotting are common side effects of medroxyprogesterone. Additionally, increasing calcium intake is often advised to counteract the potential bone density loss associated with this medication. Therefore, all the statements provided are correct, making option D the correct answer. Choices A, B, and C are all essential pieces of information that the healthcare provider should convey to the client regarding medroxyprogesterone.

3. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

• A. It's a minor inconvenience, which you should ignore.
• B. In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone.
• C. There is no way to predict how long it will last in each individual client.
• D. It occurs during the first trimester and near the end of the pregnancy.

Correct answer: D

Rationale: Urinary frequency is common during the first trimester and again at the end of pregnancy when the baby drops into the pelvis, putting pressure on the bladder.

5. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?

• A. I will need a second vaccination at my postpartum visit.
• B. I need a second vaccination at my postpartum visit.
• C. I was given the vaccine to protect myself from varicella.
• D. I will be tested in 3 months to confirm my immunity status.

Correct answer: B

Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is incorrect as it implies a future need for a second vaccination without a clear action plan. Option C is incorrect as the varicella vaccine is primarily for the client's protection, not others. Option D is not the appropriate action as waiting to be tested for immunity delays the necessary second vaccination.

Similar Questions