Nursing Elites

1. The healthcare provider is preparing to administer Rh immune globulin (RhoGAM) to a postpartum client. This medication is indicated for:

• A. Rh-negative individuals with Rh-positive infants
• B. Rh-positive individuals with Rh-negative infants
• C. All individuals regardless of Rh status
• D. Individuals with a history of Rh incompatibility

Correct answer: A

Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative individuals who have given birth to Rh-positive infants to prevent Rh sensitization. When an Rh-negative individual gives birth to an Rh-positive infant, there is a risk of the mother developing antibodies against the Rh-positive blood cells, which can lead to hemolytic disease of the newborn in subsequent pregnancies. Rh immune globulin is given to prevent this sensitization in Rh-negative individuals who deliver Rh-positive infants.

2. Which of the following signs or symptoms is more common in children than adults following an isolated head injury?

• A. Changes in pupillary reaction
• B. Tachycardia and diaphoresis
• C. Nausea and vomiting
• D. Altered mental status

Correct answer: C

Rationale: Nausea and vomiting are more common in children than adults following an isolated head injury. Children often present with gastrointestinal symptoms like nausea and vomiting after a head injury due to differences in physiological responses compared to adults.

3. A breastfeeding mother is experiencing nipple pain. What should the nurse instruct her to do?

• A. Use soap and water to clean her nipples
• B. Apply warm compresses to her breasts
• C. Ensure the baby is latching on properly
• D. Limit breastfeeding to every 4 hours

Correct answer: C

Rationale: When a breastfeeding mother experiences nipple pain, ensuring the baby latches on properly is essential. Proper latch-on technique can help prevent and alleviate nipple pain by ensuring the baby is effectively extracting milk and not causing undue pressure or friction on the nipple. This guidance can promote a more comfortable breastfeeding experience for the mother and improve milk transfer for the baby.

4. The healthcare provider is providing postpartum care to a client who had a vaginal delivery. Which finding would require further assessment?

• A. Perineal swelling
• B. Moderate lochia serosa
• C. Headache unrelieved by analgesics
• D. Breast engorgement

Correct answer: C

Rationale: A headache unrelieved by analgesics can be a sign of a serious condition such as preeclampsia, which is a life-threatening condition characterized by high blood pressure and often protein in the urine. Prompt assessment and intervention are crucial to prevent complications for both the mother and baby.

5. When is it MOST appropriate to clamp and cut the umbilical cord?

• A. Before the newborn has taken its first breath
• B. After the placenta has completely delivered
• C. As soon as the cord has stopped pulsating
• D. Immediately following delivery of the newborn

Correct answer: C

Rationale: The ideal time to clamp and cut the umbilical cord is when it has stopped pulsating. This allows for the transfer of remaining blood from the placenta to the newborn, which can be beneficial for the baby's health and iron stores. Clamping the cord too early can deprive the newborn of this essential blood volume. Waiting for the pulsations to cease ensures that the baby receives the maximum benefits from delayed cord clamping.

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