Nursing Elites

1. A clinic nurse reviews the record of a child just seen by a doctor and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

• A. Pallor
• B. Hyperactivity
• C. Exercise intolerance
• D. Gastrointestinal disturbances

Correct answer: C

Rationale: Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to reduced blood flow from the heart to the body. This narrowing restricts the amount of oxygenated blood that can reach various tissues, including muscles. As a result, individuals with aortic stenosis may experience exercise intolerance, as their muscles may not receive an adequate oxygen supply during physical activity. This can manifest as fatigue, shortness of breath, and overall decreased exercise capacity. Pallor (choice A) is a pale appearance that may be seen in anemia or other conditions affecting blood flow but is not specific to aortic stenosis. Hyperactivity (choice B) and gastrointestinal disturbances (choice D) are not typically associated with aortic stenosis.

2. When is a newborn considered premature?

• A. Weighs less than 6.5 pounds.
• B. Is born to a heroin-addicted mother.
• C. Is born before 37 weeks gestation.
• D. Has meconium in or around its mouth.

Correct answer: C

Rationale: A newborn is considered premature if it is born before 37 weeks gestation. Premature birth increases the risk of various health problems as the baby may not be fully developed. Choice A is incorrect because the weight alone does not determine prematurity. Choice B is incorrect as it refers to a specific situation but not a direct indicator of prematurity. Choice D is incorrect as the presence of meconium does not solely indicate prematurity.

3. You are dispatched to a residence for a child with respiratory distress. The child is wheezing and has nasal flaring and retractions. His oxygen saturation is 92%. You should:

• A. place the child in a supine position.
• B. administer high-flow oxygen.
• C. begin chest compressions.
• D. administer low-flow oxygen.

Correct answer: B

Rationale: In a scenario where a child presents with respiratory distress, wheezing, nasal flaring, retractions, and an oxygen saturation of 92%, the appropriate intervention is to administer high-flow oxygen. This helps to improve oxygenation and alleviate the respiratory distress the child is experiencing. Placing the child in a supine position can worsen their condition by affecting their ability to breathe effectively. Chest compressions are not indicated in this case as the child is not in cardiac arrest. Administering low-flow oxygen may not provide adequate oxygenation for a child in respiratory distress with a saturation of 92%. Therefore, the priority is to administer high-flow oxygen to improve oxygen levels and support the child's breathing.

4. The healthcare provider assesses a postpartum client who is 1 day post-delivery. Which finding would require immediate intervention?

• A. Lochia rubra with a few small clots
• B. Fundus firm and midline
• C. Temperature of 100.4°F (38°C)
• D. Saturated perineal pad in 15 minutes

Correct answer: D

Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding, which is abnormal postpartum. This finding could suggest hemorrhage, requiring immediate intervention to prevent further complications like hypovolemic shock. Monitoring and managing postpartum bleeding are crucial to ensure the client's safety and prevent serious consequences.

5. A new mother expresses concern about her baby's frequent hiccups. What should the nurse explain about newborn hiccups?

• A. Hiccups are a sign of respiratory distress in newborns.
• B. Hiccups indicate the baby is overeating.
• C. Hiccups are common and usually harmless in newborns.
• D. Hiccups are caused by a lack of burping.

Correct answer: C

Rationale: Newborn hiccups are common and usually harmless. They are typically caused by the baby's immature diaphragm and tend to resolve on their own. It is essential for parents to understand that hiccups in newborns are a normal phenomenon and do not necessarily indicate any underlying health issue. Choice A is incorrect because hiccups are not a sign of respiratory distress in newborns. Choice B is incorrect as hiccups do not indicate the baby is overeating. Choice D is also incorrect as hiccups are not solely caused by a lack of burping.

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