Nursing Elites

1. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

• A. Reporting the finding to the healthcare provider immediately
• B. Helping the woman stay in bed and rest
• C. Documenting the finding
• D. Performing active and passive range-of-motion exercises

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

2. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' If an 11-12-month-old child is unable to pull to a standing position, it can indicate a risk for developmental dysplasia of the hip. By 15 months of age, children should be walking, so delayed standing can be a red flag. The Trendelenburg sign is associated with gluteus medius muscle weakness, not hip dysplasia, making choice C incorrect. The Ortolani sign is used to detect congenital hip subluxation or dislocation, not developmental dysplasia, making choice D incorrect.

3. A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.

4. 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.

5. A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:

• A. light or fair complexion.
• B. exposure to sun for extended periods of time.
• C. certain diet and foods.
• D. history of bad sunburns.

Correct answer: C

Rationale: The correct answer is 'certain diet and foods.' Risk factors that increase the chances of getting skin cancer include having a light or fair complexion, a history of bad sunburns, personal or family history of skin cancer, outdoor activities with sun exposure, exposure to X-rays or radiation, exposure to certain chemicals, repeated trauma or injury resulting in scars, age over 50, male gender, and living in specific geographic locations. These factors can contribute to the development of skin cancer. Avoiding exposure to the sun, using protective clothing and sunscreen, and regular skin inspections are key preventive measures. Choice C, 'certain diet and foods,' is incorrect as diet is not a primary risk factor for skin cancer. Options A, B, and D are all valid risk factors associated with an increased risk of developing skin cancer.

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