a nurse who works in the nursery is attending the vaginal delivery of a term infant what action should the nurse complete prior to leaving the deliver
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Nursing Elites

HESI LPN

CAT Exam Practice Test

1. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete before leaving the delivery room?

Correct answer: D

Rationale: Placing ID bands on the infant and mother is crucial to ensure correct identification and prevent mix-ups. This step is essential for maintaining proper identification of the newborn and the mother, facilitating safe care delivery. Before leaving the delivery room, ensuring proper identification is a priority to prevent any errors. Obtaining the infant's vital signs may be important but does not take precedence over ensuring correct identification. Observing the infant latching onto the breast is crucial for breastfeeding initiation but can be done after proper identification. Administering a vitamin K injection is also important but should not delay the immediate identification process.

2. In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?

Correct answer: A

Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.

3. The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?

Correct answer: C

Rationale: The correct answer is C. Pleurodesis is a procedure used to prevent the re-accumulation of pleural effusion by creating adhesion between the pleurae. This helps prevent the formation of effusion fluid. Choices A, B, and D are incorrect because pleurodesis is not performed to debulk tumors, relieve empyema after pneumonectomy, or remove fluid from the intrapleural space. Understanding the purpose of pleurodesis is essential in providing accurate patient education and care.

4. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

Correct answer: A

Rationale: Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the most appropriate response. Swimming can be beneficial for the child, providing both exercise and enjoyment. Supervision can help manage any risks associated with swimming. Choice B is incorrect because the child's preference for swimming should be respected, and swimming can still offer socialization opportunities. Choice C is incorrect as it undermines the child's capability to understand the situation. Choice D is less appropriate as it does not address the child's interest in swimming and may limit beneficial physical activity.

5. Which client’s vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?

Correct answer: C

Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.

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