Nursing Elites

1. A postpartum client is being discharged and asks the nurse when she should expect her menstrual period to return if she is not breastfeeding. The nurse's best response is:

• A. In about 6 to 8 weeks
• B. In about 3 to 4 months
• C. In about 6 months
• D. In about 1 year

Correct answer: A

Rationale: For non-breastfeeding mothers, the return of menstrual periods typically occurs around 6 to 8 weeks postpartum. This timeframe may vary among individuals, but generally, hormonal changes after childbirth lead to the resumption of menstrual cycles within this period.

2. A mother visited your facility with the complaint of her child passing watery stools for two days. This is the first time the child is having such an experience. How will you describe such a visit?

• A. Initial
• B. Follow-up
• C. Routine visit
• D. None of the above

Correct answer: A

Rationale: The correct answer is 'Initial.' This visit is described as initial because it is the first time the child is experiencing these symptoms. It signifies the first encounter with healthcare professionals for this specific issue, distinguishing it from subsequent visits which would be follow-up appointments to monitor progress or routine visits for preventive care. Choice B, 'Follow-up,' is incorrect as it implies subsequent visits after the initial encounter. Choice C, 'Routine visit,' is also incorrect as it implies a scheduled visit for preventive care rather than a visit prompted by a new or acute issue. Choice D, 'None of the above,' is incorrect as one of the options accurately describes the situation, which is 'Initial.'

3. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature - hyperthermia
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

4. The mother of an 11-year-old girl confides to the nurse that her child has no interest in school activities, exercise, or even family outings. The most appropriate response by the nurse would be:

• A. I would recommend that she see a counselor at school.
• B. I would not worry; she will grow out of it.
• C. Many girls this age go through a time of malaise and disinterest.
• D. If she still feels the same way when you come back for the next well-child visit, I will recommend a therapist.

Correct answer: A

Rationale: When a child shows a lack of interest in various activities, including school, exercise, and family outings, it is essential to address the underlying reasons. Recommending that the child see a counselor at school is crucial to explore potential issues and provide appropriate support and guidance. This approach can help identify any emotional, social, or behavioral concerns the child may be experiencing and facilitate early intervention and support. Choice B is incorrect because dismissing the mother's concerns and assuming the child will grow out of it without addressing the issue is not appropriate. Choice C is incorrect because while some children may go through phases of disinterest, it is essential to investigate further rather than generalizing. Choice D is incorrect because waiting until the next visit without taking proactive steps to address the current lack of interest may delay necessary support and intervention.

5. The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?

• A. Lanugo mostly gone, little vernix remaining on the body
• B. Prominent clitoris, enlarging labia minora, patent anus
• C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
• D. Skin opaque, cracking at wrists and ankles, no visible vessels

Correct answer: B

Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.

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