Nursing Elites

1. The nurse is planning the care of a hospitalized 4-year-old. The most appropriate technique the nurse can use to reduce the stress of hospitalization for this child is to:

• A. Encourage the child to discuss their feelings.
• B. Encourage peer visitation.
• C. Encourage the child to play with safe medical equipment.
• D. Read a story to the child.

Correct answer: C

Rationale: Encouraging the child to play with safe medical equipment is the most appropriate technique to reduce stress for a hospitalized child. This technique helps familiarize the child with medical equipment in a non-threatening way, empowering them to feel more in control of the environment. Options A, B, and D may be helpful but do not directly address the child's exposure and interaction with the hospital environment, making them less effective in reducing stress in this context.

2. A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and administer supplemental oxygen. En route to the hospital, you should be MOST alert for:

• A. hypotension.
• B. combativeness.
• C. convulsions.
• D. respiratory distress.

Correct answer: C

Rationale: In a 7-year-old child with altered mental status, high fever, and a generalized rash, the most critical concern is the potential for convulsions. These symptoms could indicate a serious underlying condition, such as a febrile seizure or another type of seizure activity. Monitoring for convulsions is crucial during transport to ensure prompt intervention if they occur, as seizures can lead to additional complications and require immediate management.

3. The healthcare provider assesses a postpartum client who is 1 day post-delivery. Which finding would require immediate intervention?

• A. Lochia rubra with a few small clots
• B. Fundus firm and midline
• C. Temperature of 100.4°F (38°C)
• D. Saturated perineal pad in 15 minutes

Correct answer: D

Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding, which is abnormal postpartum. This finding could suggest hemorrhage, requiring immediate intervention to prevent further complications like hypovolemic shock. Monitoring and managing postpartum bleeding are crucial to ensure the client's safety and prevent serious consequences.

4. A postpartum client is concerned about hair loss. The nurse explains that this is:

• A. A sign of nutritional deficiency
• B. A temporary condition due to hormonal changes
• C. An indication of a thyroid disorder
• D. A result of poor hair care during pregnancy

Correct answer: B

Rationale: Hair loss postpartum is a common temporary condition caused by hormonal changes that occur after giving birth. This condition is known as postpartum alopecia and is a normal part of the postpartum period. It is important for the nurse to reassure the client that this hair loss is temporary and usually resolves on its own without the need for medical intervention. Choice A is incorrect because postpartum hair loss is primarily due to hormonal changes rather than nutritional deficiency. Choice C is incorrect as thyroid disorder is not typically the cause of postpartum hair loss. Choice D is incorrect as poor hair care during pregnancy does not cause postpartum hair loss.

5. The healthcare provider is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

• A. (+) Moro reflex
• B. Heart rate is 80 bpm
• C. Respirations are irregular
• D. Uneven head shape

Correct answer: B

Rationale: A heart rate of 80 bpm is least likely to be observed in a normal newborn. The normal heart rate range for a newborn is usually higher than 80 bpm, typically ranging from 120-160 bpm. The Moro reflex (choice A) is a normal newborn reflex, respirations being irregular (choice C) are expected due to the immature respiratory control center, and an uneven head shape (choice D) is common due to molding during vaginal delivery.

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