Nursing Elites

1. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

• A. Administer oxygen by mouth at 2L/min
• B. Gradually warm the infant under a radiant heat source
• C. Notify the pediatrician of the infant's vital signs
• D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

2. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

• A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
• B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
• C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
• D. Record the findings on the chart. They are within normal limits.

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

3. In the context of an average ejaculation, which of the following statements is true about sperm?

• A. The average count of sperm in the ejaculate is 2.5 billion.
• B. Sperm in the ejaculate find the ovum by following the current of the fluid coming from the cervix.
• C. Only 1 in 1,000 sperm in the ejaculate will ever approach an ovum.
• D. Most of the sperm in the ejaculate move about in a random pattern in the vagina.

Correct answer: C

Rationale: Out of millions of sperm released during ejaculation, only a small fraction, about 1 in 1,000, will approach the ovum. This statement is true as sperm face many obstacles and challenges on their journey to reach and fertilize an ovum. Choice A is incorrect because the average count of sperm in an ejaculate is typically in the millions, not billions. Choice B is incorrect as sperm do not find the ovum by following the current of fluid; they navigate using other mechanisms. Choice D is incorrect because while some sperm may move randomly in the vagina, the ones that approach the ovum do so through a more purposeful and directed movement.

4. What is the typical sex chromosome pattern for males?

• A. XX
• B. XYY
• C. XY
• D. XXY

Correct answer: C

Rationale: The correct answer is C: XY. In males, the typical sex chromosome pattern consists of one X chromosome and one Y chromosome. Choice A (XX) is the sex chromosome pattern for females. Choice B (XYY) is a chromosomal disorder where males have an extra Y chromosome. Choice D (XXY) is the sex chromosome pattern associated with Klinefelter syndrome, a condition where males have an extra X chromosome.

5. Humans begin life as a single cell that divides repeatedly. This cell is known as a(n):

• A. zygote.
• B. gonadotrope.
• C. embryo.
• D. chromaffin.

Correct answer: A

Rationale: A zygote is the correct answer. It is the initial cell formed when a sperm cell fertilizes an egg cell, marking the beginning of human development. Choice B, gonadotrope, is incorrect as it refers to a type of hormone-secreting cell in the pituitary gland. Choice C, embryo, is incorrect as it is the stage of development after the zygote has implanted into the uterine wall and undergone initial cell divisions. Choice D, chromaffin, is incorrect as it refers to cells found in the adrenal medulla that produce and store catecholamines.

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