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 :

✦ Site selection: The vastus lateralis is the preferred site for IM injections in newborns due to well-developed muscle and low risk of injury to nerves or blood vessels.

✦ Route: Intramuscular (IM) administration ensures rapid absorption of phytonadione (vitamin K) for effective prevention of hemorrhagic disease.

✦ Side avoidance: The deltoid is not recommended for neonates because the muscle is underdeveloped and may cause injury.

✦ Medication purpose: Phytonadione is given to prevent vitamin K deficiency bleeding, which is common in newborns.

✦ Dosage and positioning: Administering 0.5 mg IM in the left leg allows consistent practice and safety, often alternating sides if multiple injections are needed.

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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 :

✦ Normal NST: A reactive non-stress test requires two accelerations of 15 bpm above baseline lasting 15 seconds within 20 minutes (for >32 weeks gestation).

✦ Current finding: FHR increase of 10 bpm for only 10 seconds is nonreactive, insufficient to confirm fetal well-being.

✦ Implication: Nonreactive NST may indicate fetal hypoxia or compromised placental function, warranting further testing such as biophysical profile (BPP).

✦ Monitoring significance: Irregular contractions not felt, absence of late decelerations, or perceived fetal movements without acceleration criteria are generally not concerning alone.

✦ Action: The nurse should notify the provider and prepare for additional diagnostic evaluation to ensure fetal safety.

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Answer 3

Correct Answers:

Tetanus

Rationale :

✦ Immunization history: Client is at 28 weeks gestation and has no prior vaccinations, requiring protection against tetanus.

✦ Pregnancy safety: Tetanus toxoid-containing vaccines (Tdap or Td) are safe during pregnancy, preferably between 27–36 weeks to provide maternal antibodies to fetus.

✦ Other vaccines: Rubella and varicella are live vaccines and are contraindicated during pregnancy; they should be given postpartum.

✦ HPV: Human papillomavirus is not recommended during pregnancy.

✦ Maternal-fetal protection: Vaccination during pregnancy reduces neonatal tetanus risk and protects mother.

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Answer 4

Correct Answers:

Administer 500 m lactated Ringers IV bolus

Rationale :

✦ Priority action: The client is showing signs of postpartum hemorrhage unresponsive to fundal massage, which can lead to hypovolemic shock; rapid IV fluid replacement is essential to maintain circulating volume.

✦ Fluid choice: Lactated Ringer’s is isotonic and helps restore intravascular volume, supporting blood pressure and tissue perfusion.

✦ Assessment support: While urinary output monitoring is important, immediate fluid resuscitation takes precedence over evaluation alone.

✦ Other measures: Ice packs and dressing changes address comfort and incision care, not the active bleeding causing hypovolemia.

✦ Clinical rationale: Early intervention with fluids reduces the risk of shock, improves oxygen delivery to organs, and stabilizes the client for further interventions such as medication or surgical evaluation.

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Answer 5

Correct Answers:

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

Rationale :

✦ Soft uterus: A boggy (soft) uterus indicates uterine atony, the leading cause of postpartum hemorrhage, which is a priority concern requiring immediate intervention such as fundal massage and monitoring of blood loss.

✦ Large lochia rubra: Sudden increase in vaginal bleeding is a sign of active hemorrhage, necessitating rapid assessment and interventions to prevent hypovolemic shock.

✦ Lateral deviation of the uterus: Deviation from midline often indicates bladder distention, which can prevent proper uterine contraction and contribute to bleeding. Immediate bladder assessment and possible catheterization are warranted.

✦ Other findings: Blood pressure slightly elevated, pain rating 3, peripheral edema, and soft breasts are expected or stable findings and do not require immediate action.

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Answer 6

Correct Answers:

Assist the client in pulling their knees toward their abdomen.

Rationale :

✦ Purpose of McRoberts maneuver: This maneuver increases pelvic outlet diameter by flattening the sacrum and rotating the pelvis, facilitating shoulder delivery in shoulder dystocia.

✦ Client positioning: Flexing the maternal hips and bringing knees toward the abdomen is the correct action.

✦ Other interventions: Hands-and-knees positioning and fundal pressure are not part of McRoberts maneuver; suprapubic pressure may be used as a separate maneuver.

✦ Priority: Rapid application is essential to reduce risk of fetal brachial plexus injury.

✦ Effectiveness: Combined with suprapubic pressure, the maneuver increases the chance of successful shoulder delivery.

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Answer 7

Correct Answers:

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

Rationale :

✦ IVF risk: In vitro fertilization increases the likelihood of multiple gestations, which may require selective reduction to improve maternal-fetal outcomes.

✦ Education: The client should be informed of risks and interventions associated with multiple pregnancies.

✦ Other options: Avoiding donor oocytes or freezing embryos is not universally recommended; sperm is introduced into the oocyte in lab, not the uterus.

✦ Ethical considerations: Providing informed consent about all possible interventions ensures client autonomy and preparation.

✦ Clinical rationale: Awareness allows clients to plan for complications and follow-up care.

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Answer 8

Correct Answers:

A client who reports lochia rubra requiring changing perineal pads every 3 hr

Rationale :

✦ Magnesium toxicity: Absent deep tendon reflexes is a sign of magnesium sulfate toxicity, which can lead to respiratory depression and cardiac arrest.

✦ Immediate action: Notify provider and prepare to administer calcium gluconate as the antidote.

✦ Other findings: Lochia rubra every 3 hr, abdominal cramping, and 300 mL urine in 8 hr are within expected postpartum limits.

✦ Monitoring: Continuous monitoring of respiratory rate, reflexes, and urine output is essential.

✦ Priority: Early recognition prevents life-threatening complications.

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Answer 9

Correct Answers:

Previous cervical cerclage

Rationale :

✦ Cervical insufficiency: Previous cervical cerclage indicates risk for preterm birth due to structural weakness of the cervix.

✦ Other factors: Previous delivery at 37 weeks, reactive NST, or 2.5 kg baby are not high-risk indicators for preterm labor.

✦ Clinical significance: Monitoring cervical length and providing interventions like progesterone or cerclage can reduce preterm birth risk.

✦ Assessment: The nurse should review obstetric history to identify and mitigate risk factors early.

✦ Education: Client counseling about warning signs of preterm labor is essential for timely intervention.

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Answer 10

Correct Answers:

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

Rationale :

✦ Prenatal practice: Hypnosis is most effective if learned and practiced before labor, allowing better pain control and relaxation.

✦ Breathing and body control: Synchronized breathing and controlling body functions are not essential components.

✦ Pain management: Hypnosis can reduce perception of labor pain; it is not ineffective.

✦ Clinical guidance: Reinforce that prenatal preparation and practice enhance labor outcomes.

✦ Safety: Hypnosis is non-invasive, safe, and supportive for pain management in labor.

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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 antenatal 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 antenatal 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 antenatal 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.

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?