Question

A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

Answer 1

Correct Answers:

1M in left vastus lateralis

Rationale :

💉 Phytonadione (Vitamin K) is administered intramuscularly to newborns to prevent vitamin K deficiency bleeding.

💉 The vastus lateralis (thigh muscle) is the preferred site for IM injections in neonates due to muscle size and safety.

💉 The deltoid is underdeveloped in newborns and not recommended for IM administration.

💉 Subcutaneous injection would reduce absorption and is not the appropriate route for Vitamin K in newborns.

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Answer 2

Correct Answers:

An increase in fetal heart rate to 150/min above the baseline of 140/min lasting IO seconds in response to fetal movement within a 40-min testing period

Rationale :

🩺 A reactive nonstress test (NST) requires two or more accelerations (15 bpm above baseline lasting at least 15 seconds) within a 20-minute window.

🩺 In this case, a 10-second acceleration is insufficient, indicating a non-reactive NST, which requires further evaluation.

🩺 Irregular contractions and client-perceived movement are not criteria for reactivity.

🩺 Absence of late decelerations is reassuring, but does not confirm NST reactivity.

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Answer 3

Correct Answers:

Tetanus

Rationale :

🛡 The Tdap vaccine (Tetanus, Diphtheria, Pertussis) is safe and recommended during pregnancy—especially in the third trimester (27–36 weeks).

🛡 It provides passive immunity to the newborn, especially against pertussis.

🛡 Live vaccines like rubella and varicella are contraindicated during pregnancy due to fetal risk.

🛡 HPV vaccine is not recommended during pregnancy due to insufficient safety data.

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Answer 4

Correct Answers:

Evaluate urinary output.

Rationale :

🚨 A steady trickle of vaginal bleeding despite a firm fundus suggests non-uterine sources like vaginal/cervical lacerations.

🚨 Evaluating urinary output helps assess circulatory volume and perfusion—crucial in potential hemorrhage.

🚨 Ice packs and surgical dressing changes are not relevant to internal bleeding control.

🚨 IV fluids may be needed, but assessment comes first to determine ongoing loss and need for escalation.

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Answer 5

Correct Answers:

Uterine tone soft
Large amount of lochia rubra
Lateral deviation of the uterus

Rationale :

✅ 1. Uterine tone soft

✔️ A soft or “boggy” uterus is a critical concern because it indicates uterine atony, the leading cause of postpartum hemorrhage (PPH).

✔️ Uterine atony prevents effective contraction of the uterus, allowing blood vessels at the placental site to remain open, leading to ongoing blood loss.

✔️ Immediate nursing intervention is required—this includes fundal massage, reassessment, and possibly notifying the provider if bleeding persists.

✔️ Even though vital signs appear stable, uterine atony may quickly progress to hypovolemic shock if uncorrected.

Clinical Priority: High risk for hemorrhage → must act immediately.

✅ 2. Large amount of lochia rubra

✔️ A large amount of lochia rubra, especially after initial moderate bleeding, may indicate excessive uterine bleeding, possibly due to uterine atony or retained placental fragments.

✔️ This change from earlier documentation (moderate → large) suggests a worsening condition.

✔️ Excess lochia paired with a boggy uterus points to an active bleeding episode requiring close observation and rapid intervention.

✔️ Consistent heavy bleeding postpartum is not normal and should never be dismissed as "expected" without thorough evaluation.

Clinical Priority: Abnormal blood loss → assess for cause and intervene.

✅ 3. Lateral deviation of the uterus

✔️ Lateral displacement of the uterus, typically to the right, usually indicates a distended bladder.

✔️ A distended bladder interferes with uterine contraction, contributing to uterine atony and increased bleeding.

✔️ Even though the nurse noted “able to void spontaneously” at 0700, this does not guarantee complete bladder emptying, especially if lochia increased and tone worsened.

✔️ Nursing action should include assisting the client to void, or catheterization if retention is suspected.

Clinical Priority: Bladder distention = impairs involution and increases bleeding risk.

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Answer 6

Correct Answers:

Assist the client in pulling their knees toward their abdomen.

Rationale :

✔️ The McRoberts maneuver involves flexing the client’s legs tightly to the abdomen.

✔️ This widens the pelvis and flattens the lumbar spine to relieve shoulder dystocia.

✔️ Fundal pressure is contraindicated as it worsens impaction.

✔️ Hands-and-knees or suprapubic pressure may also be used, but McRoberts comes first.

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Answer 7

Correct Answers:

Inform the client about the possible need tor reduction of multiple fetuses.

Rationale :

🎯 IVF often involves implantation of multiple embryos, which increases the chance of multifetal pregnancy.

🎯 Clients should be educated about selective reduction in cases where carrying multiples poses a risk to maternal or fetal health.

🎯 Use of donor oocytes and embryo freezing are standard options in IVF, not contraindications.

🎯 IVF is not intrauterine insemination; fertilization occurs in vitro before transfer.

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Answer 8

Correct Answers:

A client who is receiving magnesium sulfate and has absent deep tendon reflexes

Rationale :

🛑 Absent DTRs are an early warning sign of magnesium sulfate toxicity.

🛑 If untreated, this can lead to respiratory depression or cardiac arrest.

🛑 Therapeutic monitoring includes reflexes, respiratory rate, and urine output.

🛑 Other findings (lochia every 3 hrs, cramping, 300 mL urine/8 hr) are within expected ranges postpartum.

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Answer 9

Correct Answers:

Previous cervical cerclage

Rationale :

🧵 A prior cerclage indicates cervical insufficiency, a strong risk factor for preterm birth.

🧵 It means the cervix dilated prematurely in past pregnancies, requiring surgical reinforcement.

🧵 Birthweight of 2.5 kg is within normal range, and 37 weeks is early term, not preterm.

🧵 A reactive NST is reassuring, not concerning.

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Answer 10

Correct Answers:

"Hypnosis can be beneficial if you practiced it during the prenatal period."

Rationale :

🌀 Hypnosis for labor pain control is most effective when practiced prenatally.

🌀 It involves deep relaxation, focused attention, and reduced awareness of discomfort.

🌀 It is not about controlling bodily functions or reliant on synchronized breathing.

🌀 Many women report successful pain relief with prenatal hypnobirthing techniques.

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QLexNursing

1 :
A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

2 :
A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

3 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

4 :
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

5 : A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Answer Options

6 :
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

8 :
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

9 :
A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

10 :
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?

QLexNursing

1 : A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

2 : A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

3 : A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

4 : A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

5 : A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Answer Options

6 : A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

7 : A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

8 : A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

9 : A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

10 : A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?

1 :
A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

2 :
A nurse is assessing the results of a no stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

3 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

4 :
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

8 :
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

9 :
A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

10 :
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following Information should the nurse Include?