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. A child with glomerulonephritis is asking for strawberries. What should the nurse do?

• A. Allow the child to eat strawberries.
• B. Restrict the child's diet.
• C. Give the child a low-protein diet.
• D. Increase the child's fluid intake.

Correct answer: B

Rationale: In glomerulonephritis, it is crucial to restrict the child's diet, particularly avoiding foods high in potassium like strawberries. Potassium restriction is essential because impaired kidney function in glomerulonephritis can lead to potassium retention, potentially causing hyperkalemia. Therefore, the nurse should restrict the child's diet to manage their condition effectively.

3. A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?

• A. Administer oral acyclovir.
• B. Apply calamine lotion to soothe itching.
• C. Encourage scratching to relieve itching.
• D. Encourage bed rest to avoid spreading the rash.

Correct answer: B

Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.

4. A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?

• A. Assess her blood pressure.
• B. Apply an ice pack to the perineum.
• C. Allow the infant to breastfeed.
• D. Massage the fundus vigorously.

Correct answer: A

Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding. Applying an ice pack to the perineum (choice B) would not address the ongoing bleeding issue. Allowing the infant to breastfeed (choice C) may not be safe if there is significant bleeding. Massaging the fundus vigorously (choice D) is contraindicated when there is continuous bleeding as it can worsen the bleeding or cause further harm.

5. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

• A. Measure bilirubin levels using transcutaneous bilirubinometry.
• B. Evaluate cord blood Coombs test results.
• C. Review maternal medical records for blood type and Rh factor.
• D. Prepare the newborn for phototherapy.

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

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