Nursing Elites

1. When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?

• A. 4
• B. 5
• C. 6
• D. 7

Correct answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

2. A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?

• A. I will keep the baby's head elevated while feeding.
• B. I will allow the baby to burp several times during each feeding.
• C. I will tilt the bottle to prevent air from entering as the baby sucks.
• D. My baby will have soft, formed yellow stools.

Correct answer: C

Rationale: Tilting the bottle to prevent air from entering as the baby sucks can lead to the baby swallowing air, causing discomfort and potential issues like colic or gas. The correct way to bottle-feed a newborn is by ensuring that the nipple is always filled with milk to avoid air intake, which can lead to problems. Keeping the baby's head elevated while feeding helps prevent choking, allowing the baby to burp several times during each feeding helps release swallowed air, and soft, formed yellow stools indicate a healthy digestion process in newborns.

3. A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?

• A. Dark green leafy vegetables
• B. Deep red or orange vegetables
• C. White bread and rice
• D. Meat, poultry, and fish

Correct answer: A

Rationale: Dark green leafy vegetables are rich in calcium, making them an excellent alternative source for individuals who dislike or cannot consume dairy products. Calcium is crucial for bone health, particularly during pregnancy, to support the developing fetus and maintain the mother's bone strength. Therefore, recommending dark green leafy vegetables ensures the client receives an adequate intake of calcium despite not liking milk. Choice B, deep red or orange vegetables, are not typically high in calcium. Choice C, white bread and rice, are not significant sources of calcium. Choice D, meat, poultry, and fish, are good sources of protein but do not provide as much calcium as dark green leafy vegetables.

4. While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?

• A. Conjunctivitis
• B. Bronze skin discoloration
• C. Sunken fontanels
• D. Maculopapular skin rash

Correct answer: C

Rationale: Sunken fontanels should be prioritized for reporting as they indicate dehydration, which is a critical concern in infants undergoing phototherapy. Dehydration can lead to serious complications, making it essential for the nurse to promptly inform the charge nurse for appropriate intervention and management. Conjunctivitis, bronze skin discoloration, and maculopapular skin rash are important findings to note, but in this scenario, sunken fontanels take precedence due to the potential severity of dehydration in infants.

5. A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?

• A. Encourage the client to perform Kegel exercises.
• B. Encourage the client to move to the left lateral position.
• C. Ask the client to rate her pain.
• D. Assist the client to the bathroom to void.

Correct answer: D

Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.

Similar Questions