Nursing Elites

1. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?

• A. Heat loss.
• B. Fluid balance.
• C. Bleeding tendencies.
• D. Hypoglycemia.

Correct answer: A

Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.

2. A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?

• A. Assess her blood pressure.
• B. Apply an ice pack to the perineum.
• C. Allow the infant to breastfeed.
• D. Massage the fundus vigorously.

Correct answer: A

Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding. Applying an ice pack to the perineum (choice B) would not address the ongoing bleeding issue. Allowing the infant to breastfeed (choice C) may not be safe if there is significant bleeding. Massaging the fundus vigorously (choice D) is contraindicated when there is continuous bleeding as it can worsen the bleeding or cause further harm.

3. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

4. What action should be implemented when preparing to measure the fundal height of a pregnant client?

• A. Have the client empty her bladder.
• B. Request the client lie on her left side.
• C. Perform Leopold's maneuvers first.
• D. Give the client some cold juice to drink.

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

5. During the admission procedure of a 6-year-old, the child states, 'I’m going to have an operation.' Which response is best for the nurse to provide to this child?

• A. Are you scared?
• B. We’re going to do everything we can to take very good care of you.
• C. Tell me what an operation is.
• D. I’m glad your mother told you why you were coming to the hospital.

Correct answer: B

Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.

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