Nursing Elites

1. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:

• A. Prevent eye infection.
• B. Dilate the pupil so the red reflex can be visualized.
• C. Clear the infant's vision.
• D. Prevent herpes infection.

Correct answer: A

Rationale: The correct answer is A: Prevent eye infection. Eye ointment, usually containing erythromycin, is applied to prevent neonatal conjunctivitis, which can be caused by bacteria present in the birth canal. It is not used to dilate the pupil, clear the infant's vision, or prevent herpes infection.

2. When assessing a child with HIV, which system should the nurse assess first?

• A. Assess the respiratory system.
• B. Assess the gastrointestinal system.
• C. Assess the cardiovascular system.
• D. Assess the neurological system.

Correct answer: A

Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.

3. The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?

• A. 150 mL/hour
• B. 250 mL/hour
• C. 50 mL/hour
• D. 275 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. The IV bag contains 20 grams of magnesium sulfate in 500 mL of solution, which means there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. Choice B, 250 mL/hour, is incorrect because it miscalculates the amount of magnesium sulfate infused per hour. Choice C, 50 mL/hour, is incorrect as it is too slow to deliver the required dose in the specified time frame. Choice D, 275 mL/hour, is incorrect as it overestimates the infusion rate and would deliver the dose too quickly.

4. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Unilateral lower leg pain.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 bpm.
• D. Soft, spongy fundus.

Correct answer: C

Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.

5. A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?

• A. Provide a bottle of electrolyte solution.
• B. Infuse normal saline intravenously.
• C. Administer an antipyretic rectally.
• D. Apply an external cooling blanket.

Correct answer: B

Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.

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