Nursing Elites

1. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?

• A. Notify the healthcare provider of the finding.
• B. Document the findings.
• C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
• D. Wait 15 minutes and then recheck the FHR.

Correct answer: B

Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.

2. What is the primary theory that explains a family's concept of health and illness?

• A. Health Belief Model
• B. Education-School-Completing Factor
• C. Family Health Expert Factor
• D. Disconnected Family Factor

Correct answer: A

Rationale: The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.

3. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

• A. "I should not put alcohol on my baby's cord 3-4 times a day."?
• B. "I should not put the baby's diaper on so that it covers the cord."?
• C. "I should call the physician if the cord becomes dark."?
• D. "I should wash my hands before and after I take care of the cord."?

Correct answer: B

Rationale: Parents should be taught not to cover the cord with a diaper to allow for air exposure and drying, preventing infection. The statement 'I should put alcohol on my baby's cord 3-4 times a day' indicates a need for further teaching as current recommendations do not include using alcohol on the cord, which can interfere with natural healing. While it is normal for the cord to turn dark as it dries, so the statement 'I should call the physician if the cord becomes dark' is accurate, it is not the best answer for this question. Washing hands before and after caring for the cord is important to prevent the transfer of pathogens, so this statement does not require further teaching.

4. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?

• A. turning out the room light and closing the door
• B. tiring the child during the evening with quiet activities
• C. identifying the child's home bedtime rituals and following them
• D. encouraging visitation by friends during the evening

Correct answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.

5. When inspecting the ears for cerumen impaction, the nurse checks for which finding?

• A. Redness and swelling of the tympanic membrane
• B. An external auditory canal that is longer than normal
• C. The presence of edema in the external auditory canal
• D. A yellowish or brownish waxy material in the external auditory canal

Correct answer: D

Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.

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