When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the healthcare provider?

130/70 mm Hg blood pressure.

1+ proteinuria.

101.2° F (38.4° C) oral temperature.

1+ pedal edema.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A blood pressure of 130/70 mm Hg is within the normal range for a pregnant woman and does not indicate a hypertensive disorder. Normal blood pressure in pregnancy can fluctuate, but this reading is well below the threshold for preeclampsia or gestational hypertension, which is typically 140/90 mm Hg or higher.

Choice B rationale

Trace or 1+ proteinuria can be a normal finding in pregnancy and does not, in isolation, suggest a significant pathology. It is important to note that proteinuria, when part of a cluster of symptoms, is a diagnostic criterion for preeclampsia; however, a 1+ reading alone is often benign and may be related to factors like dehydration.

Choice C rationale

A temperature of 101.2° F (38.4° C) is a significant finding that indicates a fever, which can be a sign of infection. An infection in a pregnant woman, especially at term, can pose a risk to both the mother and the fetus and may necessitate immediate medical intervention, such as antibiotic therapy or a more extensive workup.

Choice D rationale

Mild pedal edema is a common and expected finding in the third trimester of pregnancy due to increased blood volume and pressure on the vena cava by the gravid uterus. This physiological change often leads to fluid retention in the lower extremities and is not typically a cause for concern unless it is severe, sudden, or accompanied by other signs of preeclampsia.

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Correct Answer is B

Explanation

Choice A rationale

Allowing a child to choose an injection site may lead to an inappropriate or unsafe location. The ventrogluteal and vastus lateralis muscles are the preferred sites for intramuscular injections in children, selected based on the child's age, muscle development, and the volume of medication. Allowing a child to select an unsafe site could risk nerve or vascular injury.

Choice B rationale

Topical anesthetics, such as lidocaine/prilocaine cream, are effective in reducing the perception of pain associated with injections. They work by blocking sodium channels in neuronal membranes, preventing the propagation of pain signals to the central nervous system. Applying the cream ten minutes before the procedure allows for adequate time for the anesthetic effect to take place.

Choice C rationale

The ventrogluteal site is the preferred site for intramuscular injections in children over seven months old. The nurse should ask the child to lie on their side with the upper knee bent to a 45-degree angle. This position ensures relaxation of the gluteal muscles and allows for accurate landmarking of the greater trochanter, anterior superior iliac spine, and iliac crest, minimizing the risk of sciatic nerve injury.

Choice D rationale

Subcutaneous sites are not typically used for vitamin B12 injections. Subcutaneous injections are given into the fatty tissue below the dermis and are best for small volumes of non-irritating, water-soluble medications, such as insulin. Vitamin B12 is typically administered via the intramuscular route to ensure proper absorption into the muscle tissue.

A. This medication will help the baby's immature liver. B. This medication will improve the baby's insufficient dietary intake. C. This medication will prevent hemorrhagic disorders. D. This medication will stimulate the baby's immune system.

Correct Answer is C

Explanation

Choice A rationale

While a newborn's liver is immature and can affect coagulation, phytonadione (vitamin K) is not administered to directly improve liver function. Its primary role is to provide the necessary co-factor for the synthesis of specific clotting factors, which are produced in the liver but are vitamin K dependent.

Choice B rationale

Newborns typically have insufficient dietary intake of vitamin K, but this is a secondary issue. The primary reason for administering the medication is the lack of vitamin K in the newborn's sterile gut, which is necessary for the production of clotting factors. The medication directly addresses the risk of bleeding.

Choice C rationale

Newborns have a sterile gut at birth and are unable to synthesize vitamin K, a fat-soluble vitamin essential for the hepatic synthesis of clotting factors II, VII, IX, and X. The administration of phytonadione prevents vitamin K deficiency bleeding, also known as hemorrhagic disease of the newborn. This statement shows correct understanding of the medication's purpose.

Choice D rationale

Phytonadione is not an immune system stimulant. Its function is confined to the coagulation cascade. The medication is specifically a vitamin that acts as a co-factor in the synthesis of prothrombin and other coagulation proteins. It does not play a direct role in stimulating or modulating the infant's immune response.

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When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

The nurse plans to administer a vitamin B12 injection to a school aged child. Which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates an understanding of why the nurse is administering this medication?

Correct Answer is C

Explanation

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