A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Vitamin K was administered SUBQ in the thigh to act as a blood coagulant.

Your baby was given an injection of vitamin K to prevent bleeding.

Your baby had blood drawn to determine his hemoglobin and hematocrit levels.

We usually use the thigh when administering injections to infants.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Documenting the vital signs in the medical record is appropriate as the vital signs provided fall within expected ranges for a postpartum client. A temperature of 100.4°F (38°C) can be normal due to dehydration or exertion from labor, and bradycardia (heart rate 58 beats/minute) is common in postpartum women due to increased stroke volume and cardiac output.

Choice B rationale

Assessing the perineum for excessive lochia is important if there are concerns about postpartum hemorrhage, but it is not directly related to the provided vital signs. While lochia should be monitored, the vital signs alone do not indicate excessive bleeding or other complications.

Choice C rationale

Administering acetaminophen for a temperature of 100.4°F (38°C) may not be necessary, as this temperature can be considered within normal limits postpartum. Fever above 100.4°F may warrant medication, but the provided vital signs suggest no immediate need for intervention.

Choice D rationale

Reporting the heart rate to the healthcare provider is unnecessary because bradycardia (heart rate 58 beats/minute) is normal in postpartum women. Increased stroke volume during the postpartum period can result in lower heart rates. The vital signs provided do not indicate a cause for concern.

A. Perform a vaginal exam. B. Take vital signs. C. Palpate the bladder. D. Examine the amniotic fluid. E. Dipstick urine for protein and ketones.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.

Choice B rationale

Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.

Choice C rationale

Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.

Choice D rationale

Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.

Choice E rationale

Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Correct Answer is ["A","B"]

Explanation

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

A client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive.Which action(s) should the nurse plan to perform? Select all that apply.

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth.Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?