Nursing Elites

1. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

• A. Encourage the mother to provide total care for her infant.
• B. Provide privacy so the mother can develop a relationship with the infant.
• C. Encourage the father to provide most of the infant's care during hospitalization.
• D. Meet the mother's physical needs and demonstrate warmth toward the infant.

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

2. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?

• A. Allow the child to eat any food desired and tolerated.
• B. Provide small, frequent meals that are high in protein and calories.
• C. Offer the child preferred foods and avoid foods that are not well-tolerated.
• D. Consult with a dietitian to provide appropriate nutritional support.

Correct answer: B

Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.

3. A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?

• A. Massage the calf and foot.
• B. Extend the leg and dorsiflex the foot.
• C. Lower the leg off the side of the bed.
• D. Elevate the leg above the heart.

Correct answer: B

Rationale: During active labor, if a client complains of leg cramps, extending the leg and dorsiflexing the foot can help relieve the muscle cramps by stretching the affected muscles. This intervention promotes circulation and can alleviate discomfort associated with leg cramps.

4. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

• A. Weak cry without tears.
• B. Bulging fontanel.
• C. Visible peristaltic wave.
• D. Palpable mass in the right upper quadrant.

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

5. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

• A. Which symptom did you experience first?
• B. Are you consuming large amounts of salty foods?
• C. Have you traveled to a foreign country recently?
• D. Do you have a history of rheumatic fever?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

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