Nursing Elites

1. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

• A. Flaring of the nares.
• B. Shallow and irregular respirations.
• C. Respiratory rate of 50 breaths per minute.
• D. Abdominal breathing with synchronous chest movement.

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

2. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?

• A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
• B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
• C. I know you're upset. Would you like to talk about some activities you could do while in bed?
• D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.

Correct answer: A

Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.

3. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• A. Insert a straight urinary catheter to drain the bladder.
• B. Scan the bladder for urinary retention.
• C. Palpate the suprapubic area for fetal head position.
• D. Test the fluid with a nitrazine strip.

Correct answer: D

Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.

4. The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?

• A. Breastfeed exclusively at least every 3 to 4 hours.
• B. Condoms and contraceptive foam or gel.
• C. Rhythm method (natural family planning).
• D. Combined estrogen-progesterone oral contraceptives.

Correct answer: B

Rationale: Condoms and contraceptive foam or gel are safe options for breastfeeding mothers and do not affect milk supply.

5. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

• A. Measure bilirubin levels using transcutaneous bilirubinometry.
• B. Evaluate cord blood Coombs test results.
• C. Review maternal medical records for blood type and Rh factor.
• D. Prepare the newborn for phototherapy.

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

Similar Questions