Nursing Elites

1. In which stage do you determine if the patient has achieved the expected outcomes?

• A. Implementation
• B. Evaluation
• C. Assessment
• D. Diagnosis

Correct answer: B

Rationale: Evaluation is the correct stage in the nursing process to determine if the patient has achieved the expected outcomes. During the evaluation stage, the healthcare provider assesses the effectiveness of the care plan and decides on any necessary adjustments to reach the desired goals. Choice A, Implementation, is incorrect because this stage involves putting the care plan into action. Choice C, Assessment, is incorrect as it is the stage where data about the patient's health status is gathered. Choice D, Diagnosis, is also incorrect as it is the stage where the healthcare provider identifies the patient's health problems based on the assessment data.

2. Which of the following is an abnormal finding when assessing the abdomen of a newborn?

• A. The umbilical cord has two arteries and one vein.
• B. The presence of green vomit.
• C. The liver is palpable 1 to 2 cm below the costal margin.
• D. The abdomen is soft and nondistended.

Correct answer: B

Rationale: The correct answer is B. The presence of green vomit in a newborn is an abnormal finding and indicates a possible intestinal obstruction. This finding requires immediate attention and further investigation. Choices A, C, and D are normal findings in a newborn's abdomen assessment. A newborn typically has an umbilical cord with two arteries and one vein, a liver that may be palpable 1 to 2 cm below the costal margin due to its normal size in a neonate, and a soft, nondistended abdomen as expected in healthy newborns.

3. A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:

• A. Within the first half-hour after birth
• B. After the newborn's first bath
• C. When the newborn begins to cry
• D. After administering vitamin K

Correct answer: A

Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.

4. Mrs. Byers tells the nurse that she is very worried because her 2-year-old child does not finish his meals. What should the nurse advise the mother?

• A. Make the child seat with the family in the dining room until he finishes his meal
• B. Provide quiet environment for the child before meals
• C. Do not give snacks to the child before meals
• D. Put the child on a chair and feed him

Correct answer: C

Rationale: Providing a quiet environment can help the child focus on eating.

5. 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.

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