Nursing Elites

1. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

2. Is color blindness a sex-linked abnormality?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: The correct answer is A: TRUE. Color blindness is indeed a sex-linked abnormality as it is often associated with genes on the X chromosome. Since males have only one X chromosome, they are more likely to inherit color blindness if the gene is present. This makes color blindness more common in males. Choice B (FALSE) is incorrect because color blindness is linked to the X chromosome. Choices C (Sometimes) and D (Always) are incorrect as color blindness is consistently tied to the X chromosome.

3. A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL, hematocrit 29%, hepatitis surface antigen positive, Group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement?

• A. Transfuse 2 units of packed red blood cells.
• B. Give measles, mumps, rubella vaccine 0.5 mL.
• C. Administer ampicillin 2 grams intravenously.
• D. Inject hepatitis B immune globulin 0.5 milliliters.

Correct answer: C

Rationale: The correct intervention in this scenario is to administer ampicillin 2 grams intravenously. This is crucial to prevent Group B Streptococcus infection in the newborn during delivery. Option A, transfusing packed red blood cells, is not indicated based on the hemoglobin and hematocrit levels provided. Option B, giving measles, mumps, rubella vaccine, is not necessary at this time. Option D, injecting hepatitis B immune globulin, is not appropriate for the conditions presented in the question.

4. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?

• A. Assess bowel sounds.
• B. Continue to monitor.
• C. Assist with intubation.
• D. Rub the infant's back.

Correct answer: B

Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.

5. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?

• A. Dizziness while standing
• B. Sinus tachycardia
• C. Lower back pain
• D. Absent patellar reflexes

Correct answer: D

Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.

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