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 admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

• A. Assess deep tendon reflexes every hour.
• B. Obtain a daily weight.
• C. Continuous fetal monitoring
• D. Ambulate twice daily

Correct answer: D

Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.

3. A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

• A. Fertilization takes place in the outer third of the fallopian tube.
• B. Implantation occurs between 6 to 10 days after conception.
• C. Sperm remain viable in the woman's reproductive tract for 2 to 3 days.
• D. Bleeding or spotting can accompany implantation.

Correct answer: B

Rationale: The correct answer is B because implantation typically occurs between 6 to 10 days after conception, not 2 to 3 days. It is crucial for the nurse to intervene and provide accurate information to ensure the client receives correct education about conception. Choice A is correct as fertilization does occur in the outer third of the fallopian tube. Choice C is also accurate as sperm can remain viable in the woman's reproductive tract for 2 to 3 days. Choice D is correct as bleeding or spotting can indeed accompany implantation.

4. A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?

• A. Persistent abdominal striae
• B. Temperature 37.8° C (100.2° F)
• C. Unilateral breast pain
• D. Brownish-red discharge on day 5

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

5. When monitoring uterine contractions in a client in the active phase of the first stage of labor, which finding should the nurse report to the provider?

• A. Contractions lasting longer than 90 seconds
• B. Contractions occurring every 3 to 5 minutes
• C. Contractions are strong in intensity
• D. Client reports feeling contractions in the lower back

Correct answer: A

Rationale: During the active phase of the first stage of labor, contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, leading to decreased placental perfusion and fetal oxygenation. This finding should be reported to the provider for further evaluation and management. Choices B, C, and D are not the priority findings in this scenario. Contractions occurring every 3 to 5 minutes are within the normal range for the active phase of labor. Strong contractions and feeling contractions in the lower back are common experiences during labor and not necessarily concerning unless associated with other complications.

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