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. Which procedure is used to detect neural tube defects such as spina bifida and certain chromosomal abnormalities?

• A. Artificial insemination
• B. Amniocentesis
• C. Endometriosis
• D. Alpha-fetoprotein (AFP) assay

Correct answer: D

Rationale: The correct answer is the Alpha-fetoprotein (AFP) assay. This blood test measures the level of AFP in a pregnant woman's blood, aiding in the detection of neural tube defects and certain chromosomal abnormalities in the fetus. Choice A, artificial insemination, is a method used to facilitate fertilization and is not related to detecting fetal abnormalities. Choice B, amniocentesis, involves collecting amniotic fluid for genetic testing, not directly measuring AFP levels. Choice C, endometriosis, is a medical condition involving abnormal tissue growth and is not a procedure for detecting fetal abnormalities. Therefore, the Alpha-fetoprotein (AFP) assay is the most appropriate option for detecting neural tube defects such as spina bifida and certain chromosomal abnormalities.

3. In the prenatal record, the nurse should record for the pregnant client who has a 3-year-old child at home, a term birth, a miscarriage at 10 weeks’ gestation, and a set of twins who died within 24 hours:

• A. Gravida 2, para 1.
• B. Gravida 3, para 3.
• C. Gravida 4, para 2.
• D. Gravida 5, para 4.

Correct answer: C

Rationale: The correct answer is C: 'Gravida 4, para 2.' Gravida refers to the total number of pregnancies, including the current one. In this case, the client has been pregnant a total of 4 times, so gravida is 4. Para is the number of pregnancies that have reached viability, which is 2 in this case. The client has had a term birth and a set of twins who died within 24 hours, totaling 2 pregnancies that reached viability. Choices A, B, and D are incorrect because they do not accurately reflect the client's obstetric history based on the information provided.

4. In the structure of deoxyribonucleic acid (DNA), which of the following bases combines with thymine?

• A. Cytosine
• B. Adenine
• C. Rhodamine
• D. Serine

Correct answer: B

Rationale: The correct answer is B: Adenine. In the structure of DNA, adenine pairs with thymine through hydrogen bonding, forming one of the complementary base pairs that make up the double helix structure of DNA. Cytosine pairs with guanine, not thymine. Rhodamine and serine are not DNA bases and do not participate in DNA base pairing. Therefore, choices A, C, and D are incorrect.

5. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "Now my daughter is not getting enough to eat." Which response would be best for the nurse to make?

• A. Feed your baby hourly until you feel confident that your child is receiving enough milk.
• B. Don't worry, soon your milk will come in, and you will feel how full your breasts are.
• C. Since you are so concerned, you should probably supplement breastfeeding with formula.
• D. If your baby's urine is straw-colored, she's getting enough milk.

Correct answer: D

Rationale: Reassuring the mother that the baby's urine color can be an indicator of adequate hydration can help her feel more confident in her breastfeeding.

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