Nursing Elites

1. During the 5-minute Apgar assessment of a newborn, you note a heart rate of 130 beats/min, cyanosis in the hands and feet, and rapid respirations. The baby cries when you flick the soles of its feet and resists leg straightening. These findings correspond to an Apgar score of:

• A. 9
• B. 7
• C. 8
• D. 10

Correct answer: A

Rationale: The Apgar score is a rapid assessment tool to evaluate the newborn's transition to life outside the womb. The Apgar score is based on five components: heart rate (>100 bpm), respiratory effort (rapid breathing), muscle tone (resisting leg straightening), reflex irritability (crying when feet are flicked), and color (cyanosis to extremities). The described findings match a score of 9, indicating good overall condition and adaptation to extrauterine life.

2. What is the proper depth of chest compressions for a 9-month-old infant?

• A. 1/3 the diameter of the chest or about 1 1/2 inches.
• B. 1/4 the diameter of the chest or about 1 inch.
• C. 1/2 the diameter of the chest or about 2 inches.
• D. 1/3 the diameter of the chest or about 3/4 inch.

Correct answer: A

Rationale: When performing chest compressions on a 9-month-old infant, the proper depth is 1/3 the diameter of the chest, which equates to approximately 1 1/2 inches. This depth is crucial for effective cardiopulmonary resuscitation (CPR) in infants. Choice B, which suggests 1/4 the diameter of the chest or about 1 inch, is incorrect as it does not provide the recommended depth for infants. Choice C, stating 1/2 the diameter of the chest or about 2 inches, is too deep and may cause harm to the infant. Choice D, mentioning 1/3 the diameter of the chest or about 3/4 inch, is also incorrect as it underestimates the required depth for effective chest compressions on a 9-month-old infant.

3. Which behavior is most indicative that a 2-year-old is experiencing the initial phase of separation anxiety because his parents cannot stay all day at the hospital with him?

• A. He withdraws from the nursing staff.
• B. He cries when his parents leave.
• C. He lies quietly in bed.
• D. He cries when his parents arrive.

Correct answer: B

Rationale: The most indicative behavior of a 2-year-old experiencing the initial phase of separation anxiety due to parents not staying all day at the hospital is crying when his parents leave. This behavior is a common manifestation of separation anxiety in children, as they struggle with the absence of their primary attachment figures. Choices A, C, and D are less indicative because withdrawing from the nursing staff, lying quietly in bed, or crying when parents arrive do not specifically demonstrate the distress caused by separation from parents, which is the hallmark of separation anxiety in children.

4. A postpartum client is experiencing difficulty voiding. What should the nurse include in the care plan to assist the client?

• A. Encourage the client to drink caffeine-free beverages.
• B. Apply a warm compress to the client's lower abdomen.
• C. Encourage increased fluid intake to promote urinary flow.
• D. Assist the client with Kegel exercises.

Correct answer: B

Rationale: Applying a warm compress to the lower abdomen can help relax the muscles and stimulate voiding in postpartum clients. It promotes vasodilation, increases blood flow to the area, and can aid in relieving urinary retention. Encouraging caffeine-free beverages can also be beneficial as caffeine can irritate the bladder and worsen the situation. Increasing fluid intake helps prevent urinary stasis and promotes bladder emptying. Kegel exercises can strengthen pelvic floor muscles over time, but in the immediate situation of difficulty voiding, a warm compress is more appropriate.

5. The healthcare provider is preparing to administer Rh immune globulin (RhoGAM) to a postpartum client. This medication is indicated for:

• A. Rh-negative individuals with Rh-positive infants
• B. Rh-positive individuals with Rh-negative infants
• C. All individuals regardless of Rh status
• D. Individuals with a history of Rh incompatibility

Correct answer: A

Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative individuals who have given birth to Rh-positive infants to prevent Rh sensitization. When an Rh-negative individual gives birth to an Rh-positive infant, there is a risk of the mother developing antibodies against the Rh-positive blood cells, which can lead to hemolytic disease of the newborn in subsequent pregnancies. Rh immune globulin is given to prevent this sensitization in Rh-negative individuals who deliver Rh-positive infants.

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