A nurse is preparing to administer vitamin
K. Which of the following muscles should the nurse consider for the injection?

Deltoid

Vastus lateralis

Ventrogluteal

Dorsogluteal .

Answer and Explanation

The Correct Answer is B

Choice A rationale
The deltoid muscle is not typically used for intramuscular injections in infants due to its small size.

Choice B rationale
The vastus lateralis muscle is one of the preferred sites for intramuscular injections in infants, including the vitamin K injection. This muscle is large enough to absorb the medication, and injections here carry less risk of hitting a nerve or blood vessel.
Choice C rationale
The ventrogluteal muscle is not typically used for intramuscular injections in infants. This site is often used in older children and adults.
Choice D rationale
The dorsogluteal site is not recommended for intramuscular injections due to the risk of damaging the sciatic nerve.

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Correct Answer is D

Explanation

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.

A. Deep tendon reflexes of +1. B. 3+ protein in the urine. C. Blood pressure 148/98 mm Hg. D. 1+ pitting sacral edema.

Correct Answer is A

Explanation

Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is often associated with hyperreflexia, which would be a deep tendon reflex of +3 or +467.
Choice B rationale
3+ protein in the urine is consistent with preeclampsia. Proteinuria is a common finding in preeclampsia due to kidney involvement.
Choice C rationale
Blood pressure 148/98 mm Hg is consistent with preeclampsia. Hypertension is a key feature of preeclampsia.
Choice D rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the face and hands, is a common finding in preeclampsia.

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A nurse is preparing to administer vitamin K. Which of the following muscles should the nurse consider for the injection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is D

Explanation

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Correct Answer is A

Explanation

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A nurse is preparing to administer vitamin
K. Which of the following muscles should the nurse consider for the injection?