Nursing Elites

1. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

2. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

3. A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

• A. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
• B. Discuss options for intrauterine surgical correction of congenital defects.
• C. Reassure the client that the AFP results are likely to be a false reading.
• D. Explain that a sonogram should be scheduled for definitive results.

Correct answer: D

Rationale: An elevated alpha-fetoprotein (AFP) level in a pregnant client can indicate potential congenital anomalies in the fetus. A follow-up sonogram is necessary to provide definitive results and further evaluate the fetus for any possible abnormalities. Therefore, it is essential for the nurse to explain to the client that scheduling a sonogram is the next appropriate step to assess the fetal well-being and address any concerns regarding the elevated AFP level. Choices A, B, and C are incorrect because a repeat AFP test alone, discussing surgical correction of defects, or assuming the results are false without further evaluation are not appropriate responses when dealing with a potentially serious issue like elevated AFP levels in pregnancy.

4. Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?

• A. Swaddle the infant in a warm blanket.
• B. Obtain a heel stick blood glucose level.
• C. Place a pulse oximeter on the heel.
• D. Document the findings in the record.

Correct answer: B

Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.

5. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?

• A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
• B. Pyloric obstruction causes reflux and projectile hematemesis.
• C. Partial imperforated anal opening limits passage of stools.
• D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.

Correct answer: A

Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.

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