Nursing Elites

1. Fred, a 12-year-old boy, is diagnosed with pneumococcal pneumonia. Which of the following symptoms would Nurse Nica expect to assess?

• A. Mild cough
• B. Slight fever
• C. Chest pain
• D. Bulging fontanel

Correct answer: C

Rationale: Chest pain is a common symptom associated with pneumococcal pneumonia. It can occur due to inflammation of the pleura or irritation of the lung tissue, leading to sharp or stabbing pain that worsens with breathing or coughing. While cough and fever are also common with pneumonia, chest pain is particularly significant in this case.

2. You have just delivered a baby girl. Your assessment of the newborn reveals that she has a patent airway, is breathing adequately, and has a heart rate of 130 beats/min. Her face and trunk are pink, but her hands and feet are cyanotic. You have clamped and cut the umbilical cord, but the placenta has not yet delivered. You should:

• A. reassess the newborn every 5 minutes and transport after the placenta delivers.
• B. keep the newborn warm, give oxygen to the mother if needed, and transport.
• C. massage the lower part of the mother's uterus until the placenta delivers.
• D. give the newborn high-flow oxygen via a non-rebreathing mask and transport.

Correct answer: B

Rationale: In this scenario, the appropriate action is to keep the newborn warm, ensure the mother receives oxygen if needed, and prepare for transport. The newborn is showing signs of central cyanosis (hands and feet being cyanotic), which can be due to various reasons, including inadequate oxygenation. Therefore, ensuring warmth and possible oxygen to the mother are important. Additionally, monitoring both the mother and baby during transport is crucial for their well-being.

3. A postpartum client is concerned about hair loss. The nurse explains that this is:

• A. A sign of nutritional deficiency
• B. A temporary condition due to hormonal changes
• C. An indication of a thyroid disorder
• D. A result of poor hair care during pregnancy

Correct answer: B

Rationale: Hair loss postpartum is a common temporary condition caused by hormonal changes that occur after giving birth. This condition is known as postpartum alopecia and is a normal part of the postpartum period. It is important for the nurse to reassure the client that this hair loss is temporary and usually resolves on its own without the need for medical intervention. Choice A is incorrect because postpartum hair loss is primarily due to hormonal changes rather than nutritional deficiency. Choice C is incorrect as thyroid disorder is not typically the cause of postpartum hair loss. Choice D is incorrect as poor hair care during pregnancy does not cause postpartum hair loss.

4. During the pediatric assessment process, which scenario would be the LEAST appropriate for the transition phase?

• A. A parent is available to help keep the child calm.
• B. The child is unstable and needs rapid transport.
• C. You determine that the child's condition is stable.
• D. Your transport time is greater than 30 minutes.

Correct answer: B

Rationale: During a pediatric assessment, the transition phase is a critical period where care is handed over from prehospital providers to the hospital team. If the child is unstable and requires rapid transport, it is not appropriate to delay for a transition phase. In such cases, immediate transport to a higher level of care is paramount to ensure the child's safety and well-being. Choice A is appropriate as having a parent present can help keep the child calm during the transition. Choice C is also appropriate as transitioning a stable child allows for a smoother handover. Choice D, while indicating a longer transport time, does not necessarily affect the need for a transition phase as long as the child's condition remains stable.

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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