Nursing Elites

1. 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.

2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 g/dl and a hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?

• A. Carrots
• B. Chicken
• C. Yogurt
• D. Cheese

Correct answer: B

Rationale: During pregnancy, it is common for women to experience a drop in hemoglobin levels, leading to anemia. Chicken is a good dietary source of iron, which is essential for increasing hemoglobin levels. Iron from animal sources, such as chicken, is more readily absorbed by the body compared to plant-based sources. Therefore, encouraging the client to include chicken in her diet can help improve her hemoglobin levels and combat anemia.

3. A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?

• A. Encourage the parents to report this to the healthcare provider.
• B. Acknowledge the parents' observation.
• C. Schedule the newborn for further neurological testing.
• D. Explain the newborn’s normal stepping reflex.

Correct answer: D

Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.

4. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

5. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

• A. Provide information about the high-risk nature of her pregnancy.
• B. Gently remind the client that anti-rejection drugs can cause sterility.
• C. Explain the benefits of waiting for a five-year post-transplant period.
• D. Determine if the client is considering options for adopting a child.

Correct answer: A

Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.

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