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 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.

3. At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?

• A. Round ligament strain.
• B. Chorioamnionitis.
• C. Abruptio placentae.
• D. Viral infection.

Correct answer: B

Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. Chorioamnionitis is a serious condition that requires prompt recognition and treatment to prevent maternal and fetal complications. Round ligament strain (Choice A) typically presents with sharp, stabbing pain on the sides of the abdomen and is not associated with fever or uterine tenderness. Abruptio placentae (Choice C) presents with sudden-onset vaginal bleeding and severe abdominal pain, often with a board-like uterus. Viral infections (Choice D) may present with a variety of symptoms, but the combination of fever, abdominal tenderness, and gestational age in this scenario points more towards chorioamnionitis.

4. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?

• A. Alert the neonatal team and prepare for neonatal resuscitation
• B. Notify the healthcare provider from the client’s bedside
• C. Obtain written consent for an emergency cesarean section
• D. Draw a blood sample for stat hemoglobin and hematocrit

Correct answer: B

Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.

5. A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child’s plan of care?

• A. Ambulation with a walking cast.
• B. Pin and incision care after surgery.
• C. Use of injections for pain control.
• D. Administration of growth hormone.

Correct answer: B

Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.

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