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. What is the process in which the double helix of deoxyribonucleic acid (DNA) duplicates?

• A. Amniocentesis
• B. Mitosis
• C. Meiosis
• D. Mutation

Correct answer: B

Rationale: Mitosis is the correct answer because it is the process of cell division in which a cell duplicates its DNA and divides into two identical daughter cells. During mitosis, the DNA is replicated, and each daughter cell receives an identical copy of the genetic material. Amniocentesis is a medical procedure to collect amniotic fluid for prenatal genetic testing and is not related to DNA duplication. Meiosis is a type of cell division that produces gametes with half the genetic material of the parent cell, leading to genetic diversity. Mutation is a permanent alteration in the DNA sequence that can lead to genetic variations but is not the process of DNA duplication.

3. Once the testes have developed in the embryo, they begin to produce male sex hormones, or _____.

• A. androgens
• B. genotypes
• C. blastocysts
• D. teratogens

Correct answer: A

Rationale: Androgens are male sex hormones, such as testosterone, produced by the testes after they have developed in the embryo. Androgens are responsible for the development of male secondary sexual characteristics. Genotypes refer to an individual's genetic makeup, not hormones. Blastocysts are early stage embryos, not male sex hormones. Teratogens are substances that can interfere with fetal development, not male sex hormones produced by the testes.

4. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound, 10-ounce (3220-gram) infant. Which information should the nurse provide to the client about these findings?

• A. The uterus should be firm to prevent an intrauterine infection.
• B. Both the lower uterine segment and the fundus must be massaged.
• C. A firm uterus prevents the endometrial lining from being sloughed.
• D. Clots may form inside a boggy uterus and need to be expelled.

Correct answer: D

Rationale: After childbirth, a boggy uterus indicates poor uterine tone, which can lead to the formation of clots. Massaging the fundus helps the uterus contract and expel clots, reducing the risk of postpartum hemorrhage. Choices A, B, and C are incorrect because the main concern with a boggy uterus is the risk of clot formation and postpartum hemorrhage, not solely preventing intrauterine infection, massaging the lower uterine segment, or preventing the endometrial lining from sloughing.

5. Which of the following pairs share 100% of their genes?

• A. Biovular twins
• B. Fraternal twins
• C. Dizygotic (DZ) twins
• D. Monozygotic (MZ) twins

Correct answer: D

Rationale: The correct answer is Monozygotic (MZ) twins. Monozygotic twins, also known as identical twins, share 100% of their genes because they originate from the same fertilized egg that splits into two. Fraternal twins (choice B), also known as dizygotic (DZ) twins (choice C), result from two separate fertilized eggs and share approximately 50% of their genes. Biovular twins (choice A) is not a term used in genetics and does not describe a type of twinning.

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