A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

Ventrogluteal

Vastus lateralis

Dorso-gluteal

Deltoid

Answer and Explanation

The Correct Answer is B

A.   The ventrogluteal site can be used for IM injections in older infants but is not typically used in newborns.
B.   The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and accessibility.
C.   The dorso-gluteal site is not recommended for IM injections in infants due to the risk of injury to the sciatic nerve.
D.   The deltoid muscle is not typically used for IM injections in newborns due to its small size and less developed musculature.

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Correct Answer is D

Explanation

A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.

A. Administer thyroid hormone replacement. B. Educate parents on blood glucose monitoring. C. Obtain a blood sample for blood type. D. Initiate a controlled low-protein diet.

Correct Answer is D

Explanation

A. Administering thyroid hormone replacement is not indicated for phenylketonuria (PKU). PKU is a metabolic disorder involving the inability to metabolize phenylalanine, an amino acid, and it does not involve thyroid dysfunction.
B. Blood glucose monitoring is not directly related to the management of PKU. In PKU, the focus is on monitoring and restricting phenylalanine intake, not blood glucose levels.
C. Obtaining a blood sample for blood type may be necessary for general newborn screening but is not specific to the management of PKU.
D. Initiating a controlled low-protein diet is the cornerstone of management for PKU. This diet restricts phenylalanine intake, which is essential for preventing neurological damage and
developmental delays in affected infants.

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A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is D

Explanation

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Correct Answer is D

Explanation

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