Nursing Elites

1. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?

• A. Bathe the infant with an antimicrobial soap.
• B. Measure the head and chest circumference.
• C. Obtain the infant's footprints.
• D. Administer vitamin K (AquaMEPHYTON).

Correct answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.

2. A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?

• A. Administer oral acyclovir.
• B. Apply calamine lotion to soothe itching.
• C. Encourage scratching to relieve itching.
• D. Encourage bed rest to avoid spreading the rash.

Correct answer: B

Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.

3. At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?

• A. Estimated amount of fluid.
• B. Any odor noted when membranes ruptured.
• C. Color and consistency of fluid.
• D. Time the membranes ruptured.

Correct answer: C

Rationale: The color and consistency of the amniotic fluid are crucial to assess as they can provide valuable information about the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can lead to complications such as meconium aspiration syndrome in the newborn. Therefore, assessing the color and consistency of the amniotic fluid is the priority in this situation to ensure timely interventions if needed. Estimated amount of fluid (Choice A) may be important but not as critical as assessing for meconium. Any odor noted when membranes ruptured (Choice B) is less relevant compared to assessing for meconium. Knowing the time the membranes ruptured (Choice D) is important but does not take precedence over assessing for fetal distress indicated by meconium presence.

4. A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?

• A. Gravidity and parity.
• B. Time and amount of last oral intake.
• C. Date of last normal menstrual period.
• D. Frequency and intensity of contractions.

Correct answer: C

Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus. Choices A, B, and D are important in labor assessment, but in this scenario, the most crucial information needed is the date of the last normal menstrual period to estimate the gestational age.

5. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

• A. Flaring of the nares.
• B. Shallow and irregular respirations.
• C. Respiratory rate of 50 breaths per minute.
• D. Abdominal breathing with synchronous chest movement.

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

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