Nursing Elites

1. While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child’s bedside. Which instruction best supports the family's involvement?

• A. While waiting for the healthcare provider, only one visitor may stay with the child.
• B. All of you should leave while the healthcare provider sutures the child’s forehead.
• C. It is best if the sibling goes to the waiting room until the suturing is completed.
• D. Please decide who will stay when the healthcare provider begins suturing.

Correct answer: D

Rationale: Involving the family by letting them decide who will stay during the suturing process promotes family engagement and comfort, ensuring the presence of a familiar person for the child during the procedure.

2. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

3. 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.

4. The nurse is caring for a client who experienced fetal demise at 32 weeks' gestation. After the fetus is delivered vaginally, the nurse implements fetal demise protocol and identification procedures. Which action is most important for the nurse to take?

• A. Create a memory box with the baby's footprint and photographs.
• B. Determine if the mother desires a visit from her clergy.
• C. Encourage the mother to hold and spend time with her baby.
• D. Explain the reasons for obtaining consent for an infant autopsy.

Correct answer: C

Rationale: Encouraging the mother to hold and spend time with her baby is crucial after a fetal demise at 32 weeks' gestation. This action can support the mother in the grieving process, facilitate bonding, and provide closure, helping her cope with the loss of the baby. Creating a memory box with the baby's footprint and photographs could be emotionally comforting but not as immediate and impactful as encouraging direct physical contact. While offering a visit from her clergy may provide spiritual support, the immediate need is to address the physical and emotional aspects of the situation. Explaining the reasons for obtaining consent for an infant autopsy is important, but it is secondary to the immediate emotional support needed by the mother.

5. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

• A. Recommend explaining the normal physiological changes during pregnancy.
• B. Notify the healthcare provider of the complaint.
• C. Inform her that this is a normal physiological change.
• D. Prepare to provide education on vaginal health.

Correct answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

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