Nursing Elites

1. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

• A. Elicit a positive scarf sign on the affected side.
• B. Observe for an asymmetrical Moro (startle) reflex.
• C. Watch for swelling of fingers on the affected side.
• D. Note paralysis of the affected extremity and muscles.

Correct answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

2. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

3. A neonate with congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

• A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
• B. Support the parents in their decision regarding the sex assignment of their child
• C. Offer information about ultrasonography and genotyping to determine sex assignment
• D. Explain that corrective surgical procedures consistent with sex assignment can be delayed

Correct answer: B

Rationale: Supporting the parents in their decision regarding the sex assignment of their child is crucial as it respects the parental role in making this important decision and helps provide emotional support during a challenging time. The primary focus should be on helping the parents navigate the complexities and implications of determining the sex assignment for their child with ambiguous genitalia.

4. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?

• A. Bathe the infant with an antimicrobial soap.
• B. Measure the head and chest circumference.
• C. Obtain the infant's footprints.
• D. Administer vitamin K (AquaMEPHYTON).

Correct answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.

5. A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?

• A. Ask the client’s mother to call an ambulance for transport to the hospital immediately.
• B. Determine what physical activities the client has performed for the past 24 hours.
• C. Teach the client how to perform pelvic rock exercises and observe for correct feedback.
• D. Ask the client if she has experienced any recent changes in vaginal discharge.

Correct answer: D

Rationale: The priority nursing intervention in this situation is to ask the client if she has experienced any recent changes in vaginal discharge. Changes in vaginal discharge can indicate preterm labor, making it crucial to assess promptly. This information will help determine if the client needs immediate medical attention and appropriate interventions to prevent preterm birth and ensure the well-being of the mother and the baby. Option A is not the priority as back pain alone does not warrant immediate ambulance transport. Option B is less relevant in this context as the focus should be on immediate concerns related to pregnancy. Option C is not the priority as addressing back pain should come after ruling out urgent pregnancy-related issues.

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