Nursing Elites

1. A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions?

• A. I should mix the medication in the baby food and give it when I feed the child
• B. I should administer the oral medication sitting in an upright position and with the head elevated
• C. I will give my child a toy after giving the medication
• D. I will offer my child a juice drink after swallowing the medication

Correct answer: A

Rationale: Mixing medication in baby food is not recommended as it can alter the taste and the child may refuse food.

2. What characteristic indicates that a mass on a newborn's head is a cephalohematoma?

• A. The mass appears on the second day after birth.
• B. The mass grows larger when the newborn cries.
• C. The head appears asymmetrical.
• D. The mass is located on only one side of the head.

Correct answer: A

Rationale: A cephalohematoma typically appears between the first and second days after birth, making choice A the correct answer. It results from blood vessel rupture between a cranial bone and the periosteal membrane. Choices B, C, and D are incorrect because the growth of the mass when the newborn cries, asymmetrical head appearance, or the mass being located on only one side of the head are not specific indicators of a cephalohematoma.

3. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. In addition to administering high-flow oxygen, treatment should include:

• A. treating for shock and uterine massage during transport.
• B. uterine massage and transport.
• C. placing her on her left side and transport.
• D. internal vaginal pads and treating for shock during transport.

Correct answer: A

Rationale: In this scenario, the mother is showing signs of postpartum hemorrhage with increased heart rate, diaphoresis, and mild vaginal bleeding. The correct approach involves treating for shock by addressing hypovolemia and providing uterine massage to help control bleeding. Administering high-flow oxygen is essential. Therefore, the most appropriate option is to treat for shock and perform uterine massage during transport to manage the postpartum hemorrhage effectively.

4. When teaching a new mother how to perform perineal care, which instruction should be included?

• A. Use a front-to-back motion when cleaning the perineal area
• B. Use a peri-bottle filled with warm water after each voiding
• C. Avoid using any cleansing solution on the perineal area
• D. Apply powder to the perineal area to keep it dry

Correct answer: B

Rationale: Using a peri-bottle filled with warm water after each voiding is essential for proper perineal care as it helps cleanse the area without causing irritation and promotes healing. It is important to avoid using a back-to-front motion to prevent introducing bacteria into the urethra, and using powder may increase the risk of infection. Cleansing solutions specifically formulated for perineal care may be recommended but should be used under healthcare provider guidance.

5. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 80 beats/min. What is the MOST appropriate initial management for this newborn?

• A. Assess the newborn's skin condition and color.
• B. Initiate positive-pressure ventilations.
• C. Start chest compressions and contact medical control.
• D. Provide blow-by oxygen with oxygen tubing.

Correct answer: B

Rationale: In a newborn with a heart rate below 100 beats/min, the most appropriate initial management is to initiate positive-pressure ventilations. This helps support the newborn's respiratory effort and oxygenation in the setting of a low heart rate, ensuring adequate oxygen supply to vital organs. Assessing the skin condition and color, starting chest compressions, or providing blow-by oxygen are not the priority in this scenario where respiratory support is crucial.

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