Nursing Elites

1. The nurse is preparing to administer erythromycin eye ointment to a newborn. The mother asks why this is necessary. What is the nurse's best response?

• A. It helps to prevent eye infections caused by bacteria in the birth canal.
• B. It protects the baby's eyes from bright lights in the delivery room.
• C. It prevents the development of jaundice.
• D. It helps the baby see more clearly after birth.

Correct answer: A

Rationale: Erythromycin eye ointment is administered to newborns to prevent eye infections caused by bacteria present in the birth canal. This ointment does not have a direct correlation with protecting the baby's eyes from bright lights, preventing jaundice, or improving the baby's vision clarity post-birth.

2. 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.

3. You arrive at a residence shortly after a 4-year-old boy experienced an apparent febrile seizure. The child is alert and crying. His skin is flushed, hot, and moist. His mother tells you that the seizure lasted about 2 minutes. You should:

• A. provide supportive care and transport.
• B. give him acetaminophen or ibuprofen.
• C. begin rapid cooling measures at once.
• D. allow the mother to take her child to the doctor.

Correct answer: A

Rationale: After a febrile seizure, the recommended course of action is to provide supportive care and transport the child to a medical facility. Supportive care may include ensuring a safe environment, monitoring the child, and seeking medical evaluation to determine the underlying cause of the seizure and appropriate management.

4. A 6-year-old male is hospitalized in stable condition with multiple fractures following a car accident. The child's parents tell the nurse that their 7-year-old daughter is very upset about the accident and is concerned that her brother will die. Which suggestion by the nurse is most appropriate?

• A. Encourage the parents to phone the sister frequently with updates on her brother's condition.
• B. Suggest that the sister come to the hospital for a visit.
• C. Suggest that one parent leave the hospital to spend extra time with their daughter at home.
• D. Remind the parents that it is normal for children to be upset when their sibling is hospitalized.

Correct answer: B

Rationale: In situations where a sibling is upset about a family member being hospitalized, suggesting that the sister come to the hospital for a visit can help alleviate her concerns. This allows the sister to see her brother, ask questions, and receive reassurance from seeing him in stable condition. Direct contact and interaction can often provide more comfort and understanding than phone calls or staying at home. Encouraging phone calls (Choice A) might not provide the same level of comfort as a physical visit. While spending extra time with the daughter at home (Choice C) is important, in this scenario, facilitating a visit to the hospital can address the daughter's immediate concerns better. Reminding the parents that it is normal for children to be upset (Choice D) is not as proactive as arranging for the sister to visit her brother.

5. What is the most appropriate action to prevent heat loss in a newborn immediately after birth?

• A. Place the newborn in an incubator
• B. Bathe the newborn right away
• C. Dry the newborn thoroughly
• D. Feed the newborn

Correct answer: C

Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.

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