Nursing Elites

1. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

• A. Insert a gloved finger into the mother's vagina to feel for cord compression
• B. Position the mother so that her hips are elevated
• C. Notify the registered nurse
• D. Perform a vaginal examination on the mother

Correct answer: B

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

2. 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 put alcohol on my baby's cord 3-4 times a day."?
• B. "I should 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: A

Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.

3. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

• A. maintaining adequate tissue perfusion
• B. demonstrating behaviors that reduce fears
• C. restored body integrity
• D. remaining free of infection

Correct answer: C

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

4. The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?

• A. ''I should eat five or six small meals a day rather than three full meals.''
• B. ''I need to be sure not to drink liquids with my meals.''
• C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
• D. ''I need to avoid eating fried or greasy foods.''

Correct answer: B

Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.

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

• A. Health Belief Model
• B. Education Factor
• C. Family Health Belief Model
• D. Family Dynamics Model

Correct answer: A

Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.

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