Nursing Elites

1. After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?

• A. The new formula is a coconut milk formula used with babies with impaired fat absorption.
• B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea.
• C. The new formula is a casein protein source that is low in phenylalanine.
• D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

Correct answer: D

Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.

2. After a client delivered vaginally 2 days ago, what information should you share with her if she wants to resume using her diaphragm for birth control?

• A. The diaphragm is the most effective form of contraception.
• B. The diaphragm must be refitted after childbirth.
• C. Vaseline lubricant should be used when inserting the diaphragm.
• D. The diaphragm should be inserted 2 to 4 hours before intercourse.

Correct answer: B

Rationale: After childbirth, the diaphragm must be refitted to ensure a proper fit and effectiveness. Changes in the body post-delivery can affect the fit of the diaphragm, making it necessary to get refitted. Choice A is incorrect because while the diaphragm can be effective, it is not the most effective form of contraception. Choice C is incorrect because oil-based lubricants like Vaseline can damage latex diaphragms. Choice D is incorrect because the diaphragm should be inserted no more than 2 hours before intercourse, not 2 to 4 hours.

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. During a well-child visit for their child, one of the parents with an autosomal dominant disorder tells the nurse, 'We don’t plan on having any more children, since the next child is likely to inherit this disorder.' How should the nurse respond?

• A. Explain that the risk of inheriting the disorder decreases by 50% with each child the couple has.
• B. Acknowledge that the next child will inherit the disorder since the first child did not.
• C. Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked.
• D. Confirm that there is a 50% chance of their future children inheriting the disorder.

Correct answer: D

Rationale: Confirming that there is a 50% chance of their future children inheriting the disorder is the correct response in this situation. Autosomal dominant disorders have a 50% chance of being passed on to each child. Providing accurate genetic counseling is essential to help the parents make informed decisions about family planning. Choices A, B, and C are incorrect. Choice A is inaccurate because the risk of inheriting an autosomal dominant disorder remains at 50% for each child regardless of the number of children the couple has. Choice B is not appropriate as it does not provide helpful information or support to the parents. Choice C is misleading because autosomal dominant disorders follow a specific inheritance pattern and are not sex-linked.

5. 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.

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