Nursing Elites

1. Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?

• A. Initiate positive pressure ventilation.
• B. Intervene after the one-minute Apgar assessment.
• C. Initiate CPR on the infant.
• D. Assess the infant's blood glucose level.

Correct answer: A

Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.

2. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

• A. Weight gain.
• B. Reduction of fever.
• C. Improved caloric intake.
• D. Reduction of edema.

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

3. The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?

• A. Bilirubin of 1.5 mg/dl.
• B. Glucose of 80 mg/dl.
• C. Potassium of 4.5 mEq/L.
• D. Sodium of 119 mEq/L.

Correct answer: D

Rationale: Low sodium levels in congenital adrenal hyperplasia can indicate salt-wasting crisis, which is a life-threatening emergency requiring immediate medical attention. Monitoring sodium levels is crucial to prevent complications such as dehydration and shock in these patients.

4. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?

• A. Drowsiness and bradycardia.
• B. Depressed reflexes and increased respirations.
• C. Tachycardia and a feeling of nervousness.
• D. A flushed, warm feeling and a dry mouth.

Correct answer: C

Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.

5. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?

• A. Initiate an intravenous infusion.
• B. Observe the FHR pattern for 30 more minutes.
• C. Schedule a biophysical profile.
• D. Place an acoustic stimulator on the abdomen.

Correct answer: D

Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.

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