Nursing Elites

1. A newborn with a yellow abdomen and chest is being assessed. What should be the nurse's initial action?

• A. Assess bilirubin level.
• B. Administer phototherapy.
• C. Encourage feeding to help reduce bilirubin levels.
• D. Perform a bilirubin test every hour.

Correct answer: A

Rationale: The correct action when assessing a newborn with a yellow abdomen and chest is to initially assess the bilirubin level. This helps determine the severity of jaundice in the newborn. Administering phototherapy (choice B) is a treatment intervention that follows the assessment. Encouraging feeding (choice C) can help with bilirubin excretion but is not the initial assessment. Performing a bilirubin test every hour (choice D) may not be necessary initially and could lead to unnecessary interventions.

2. During a well-child visit for their child, one of the parents with an autosomal dominant disorder tells the nurse, 'We don’t plan on having any more children, since the next child is likely to inherit this disorder.' How should the nurse respond?

• A. Explain that the risk of inheriting the disorder decreases by 50% with each child the couple has.
• B. Acknowledge that the next child will inherit the disorder since the first child did not.
• C. Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked.
• D. Confirm that there is a 50% chance of their future children inheriting the disorder.

Correct answer: D

Rationale: Confirming that there is a 50% chance of their future children inheriting the disorder is the correct response in this situation. Autosomal dominant disorders have a 50% chance of being passed on to each child. Providing accurate genetic counseling is essential to help the parents make informed decisions about family planning. Choices A, B, and C are incorrect. Choice A is inaccurate because the risk of inheriting an autosomal dominant disorder remains at 50% for each child regardless of the number of children the couple has. Choice B is not appropriate as it does not provide helpful information or support to the parents. Choice C is misleading because autosomal dominant disorders follow a specific inheritance pattern and are not sex-linked.

3. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn?

• A. Length of labor and method of delivery.
• B. Infant's condition at birth and treatment received.
• C. Feeding method chosen by the parents.
• D. History of drugs given to the mother during labor.

Correct answer: B

Rationale: When a full-term infant is transferred to the nursery, the most crucial information for the LPN/LVN to receive for immediate care planning is the infant's condition at birth and any treatments received. This data helps in determining the initial care needs and monitoring requirements for the newborn. Choices A, C, and D are not as critical as the infant's condition at birth and treatment received. The length of labor and method of delivery may provide background information but may not be as essential for immediate care planning. The feeding method chosen by the parents and the history of drugs given to the mother during labor are important but do not take precedence over knowing the infant's condition and treatment received.

4. During the admission procedure of a 6-year-old, the child states, 'I’m going to have an operation.' Which response is best for the nurse to provide to this child?

• A. Are you scared?
• B. We’re going to do everything we can to take very good care of you.
• C. Tell me what an operation is.
• D. I’m glad your mother told you why you were coming to the hospital.

Correct answer: B

Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.

5. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

• A. Patellar reflex 4+
• B. Blood pressure 158/80
• C. Four-hour urine output 240 ml
• D. Respirations 12/minute

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

Similar Questions