Nursing Elites

1. During an examination for possible cryptorchidism in an infant, what technique should be used?

• A. Place the infant in a warm room and use a calm approach.
• B. Hold the scrotum and palpate gently.
• C. Cleanse the penis with an antiseptic-soaked pad.
• D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

2. An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?

• A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
• B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
• C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
• D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.

Correct answer: D

Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.

3. The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care?

• A. Blood pressure 76/42 mmHg.
• B. Faint heart murmur.
• C. Respiratory rate of 76 breaths/minute.
• D. Blood glucose 45 mg/dl.

Correct answer: C

Rationale: A high respiratory rate in a newborn is concerning as it may indicate respiratory distress, which requires immediate attention to ensure adequate oxygenation. Monitoring and addressing respiratory issues take precedence over other parameters in the initial assessment of a newborn. The blood pressure, heart murmur, and blood glucose levels are important but not as urgent as addressing potential respiratory distress in a newborn.

4. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?

• A. Provide an opportunity for the parents to hold their infant in privacy.
• B. Assist the couple in completing a request for autopsy.
• C. Encourage the couple to seek family counseling within the next few weeks.
• D. Explain the possible causes of fetal demise.

Correct answer: A

Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.

5. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

• A. Turn the client to her left side
• B. Contact the healthcare provider
• C. Assess the fetal heart rate
• D. Check the cervical dilation

Correct answer: C

Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.

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