Nursing Elites

1. The healthcare provider is assessing a newborn who is 2 hours old. Which finding requires immediate intervention?

• A. Acrocyanosis
• B. Respiratory rate of 60 breaths per minute
• C. Grunting with nasal flaring
• D. Heart rate of 140 beats per minute

Correct answer: C

Rationale: Grunting with nasal flaring is a concerning sign of respiratory distress in a newborn that can indicate inadequate oxygenation. This finding requires immediate intervention to ensure the newborn's respiratory status is stabilized and to prevent further complications. Prompt assessment and appropriate intervention are crucial in such cases to prevent respiratory compromise and potential deterioration. Acrocyanosis, which is bluish discoloration of the extremities, is a common finding in newborns and usually resolves on its own. A respiratory rate of 60 breaths per minute and a heart rate of 140 beats per minute are within normal ranges for a newborn and do not indicate immediate intervention is needed.

2. The healthcare provider is caring for a newborn who is 2 days old. Which finding should be reported to the healthcare provider?

• A. Yellowing of the skin
• B. Presence of a small amount of blood in the diaper
• C. Peeling skin on the hands and feet
• D. Intermittent episodes of sneezing

Correct answer: A

Rationale: Yellowing of the skin may indicate jaundice in a newborn, which can be a sign of an underlying health issue such as an elevated bilirubin level. It is essential to report this finding to the healthcare provider for further assessment and appropriate management to prevent complications.

3. The provider is educating the parents of a newborn about circumcision care. Which of the following instructions should be included?

• A. Cleanse the penis with each diaper change using alcohol wipes.
• B. Avoid using petroleum jelly on the circumcision site.
• C. Report any yellowish exudate around the head of the penis.
• D. Use warm water to clean the penis gently during diaper changes.

Correct answer: D

Rationale: The correct instruction for circumcision care is to use warm water to gently clean the penis during diaper changes. Alcohol wipes should be avoided as they can cause irritation. Yellowish exudate around the head of the penis is a normal part of the healing process and does not require reporting unless accompanied by other concerning symptoms. Avoiding petroleum jelly on the circumcision site is important to prevent trapping moisture and bacteria, which can lead to infection.

4. A postpartum client is being discharged. The nurse should include which information about postpartum depression?

• A. It can occur at any time postpartum
• B. It is a serious condition that requires attention
• C. It can affect the ability to care for the newborn
• D. It may necessitate medical intervention

Correct answer: C

Rationale: Postpartum depression is a serious condition that can impact a mother's ability to care for her newborn. It is crucial for healthcare providers to educate clients about the signs and symptoms of postpartum depression, as it may necessitate medical intervention to ensure the well-being of both the mother and the newborn.

5. A postpartum client asks the nurse about resuming sexual activity. What is the nurse's best response?

• A. You can resume sexual activity as soon as you feel ready.
• B. It is best to wait until your postpartum check-up before resuming sexual activity.
• C. You should wait at least 6 weeks before resuming sexual activity.
• D. It is safe to resume sexual activity once your lochia has stopped.

Correct answer: B

Rationale: The best response for the nurse is to advise the postpartum client to wait until the postpartum check-up before resuming sexual activity. This allows for complete healing to ensure the client's well-being and provides an opportunity to address any concerns with the healthcare provider. Choice A is incorrect because resuming sexual activity should be based on medical advice rather than personal readiness. Choice C is incorrect as the 6-week recommendation is a general guideline but individual circumstances may vary. Choice D is incorrect as the cessation of lochia is not the sole indicator for safe resumption of sexual activity.

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