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?
Dorsogluteal
Vastus lateralis
Deltoid
Ventrogluteal
The Correct Answer is B
Choice A reason:
The dorsogluteal muscle is not recommended for intramuscular injections in newborns due to the risk of damaging the sciatic nerve. Additionally, this muscle is not well-developed in newborns, making it a less effective site for medication absorption.
Choice B reason:
The vastus lateralis muscle, located on the lateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. This muscle is well-developed at birth, providing a large and safe area for the injection. It also has fewer major blood vessels and nerves, reducing the risk of injury. The vastus lateralis muscle ensures effective absorption of the medication, making it the optimal choice for administering vitamin K to prevent vitamin K deficiency bleeding (VKDB).
Choice C reason:
The deltoid muscle is not typically used for intramuscular injections in newborns because it is relatively small and underdeveloped at birth. This muscle is more suitable for older children and adults, where it can accommodate larger volumes of medication without causing discomfort or injury.
Choice D reason:
The ventrogluteal muscle is another site that is not commonly used for newborns. While it is a safe and effective site for intramuscular injections in older children and adults, it is not as easily accessible in newborns. The vastus lateralis remains the preferred site due to its size and ease of access.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Administering oxygen by non-rebreather mask at 5 L/min is a common intervention for patients who may be experiencing respiratory distress or hypoxia. A non-rebreather mask can deliver high concentrations of oxygen, typically between 60% to 90% FiO2, which is crucial in emergency situations such as severe hypoxia, respiratory failure, or carbon monoxide poisoning. Given the client’s stable respiratory rate of 18/min and pulse of 80/min, this prescription does not require immediate clarification.
Choice B Reason:
Obtaining laboratory studies of prothrombin time (PT) and partial thromboplastin time (PTT) is a standard procedure to assess the blood’s clotting ability. These tests are essential for identifying any coagulation disorders, monitoring the effectiveness of anticoagulant therapy, and evaluating the risk of bleeding before surgical procedures. Given the client’s recent delivery and potential for postpartum hemorrhage, this prescription is appropriate and does not require clarification.
Choice C Reason:
Methylergonovine (Methergine) is an ergot alkaloid used to prevent or treat excessive bleeding after childbirth by inducing uterine contractions. However, it is contraindicated in patients with hypertension due to its potential to cause severe vasoconstriction and elevate blood pressure further. The client’s blood pressure is already elevated at 146/94 mm Hg, making this prescription potentially harmful and requiring clarification.
Choice D Reason:
Inserting an indwelling urinary catheter is a common practice in postpartum care to monitor urine output and prevent bladder distention, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. This intervention is appropriate for the client’s condition and does not require clarification.
Correct Answer is D
Explanation
Choice A Reason:
Using the intercostal space as a landmark for measuring chest circumference is not standard practice. The intercostal spaces are the spaces between the ribs, and using them as a reference point can lead to inconsistent measurements due to variations in rib spacing and positioning.
Choice B Reason:
The xiphoid process is the lower part of the sternum. While it is a significant anatomical landmark, it is not used for measuring chest circumference in newborns. The xiphoid process is located too low on the chest to provide an accurate and consistent measurement of chest circumference.
Choice C Reason:
The sternal notch, also known as the jugular notch, is the upper part of the sternum. Similar to the xiphoid process, it is not used for measuring chest circumference in newborns. The sternal notch is located too high on the chest and does not provide a consistent reference point for chest circumference measurements.
Choice D Reason:
The nipple line is the correct anatomical landmark for measuring the chest circumference of a newborn. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards.
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