Nursing Elites

1. A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?

• A. Encourage the parents to report this to the healthcare provider.
• B. Acknowledge the parents' observation.
• C. Schedule the newborn for further neurological testing.
• D. Explain the newborn’s normal stepping reflex.

Correct answer: D

Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.

2. The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

• A. Insert an internal fetal monitor.
• B. Assess for cervical changes q1h.
• C. Monitor bleeding from IV sites.
• D. Perform Leopold's maneuvers.

Correct answer: C

Rationale: Monitoring for bleeding from IV sites is the priority intervention in this situation. The dark red vaginal bleeding, uterine tension, and other assessment findings suggest a potential placental abruption. Monitoring bleeding from IV sites can help detect coagulopathy, which may be associated with placental abruption. Options A, B, and D are not the most appropriate interventions in this scenario. Inserting an internal fetal monitor, assessing for cervical changes, and performing Leopold's maneuvers are not the priority actions when dark red vaginal bleeding and uterine tension are present, indicating a potential emergency situation.

3. What should the nurse recommend to a woman with mastitis?

• A. Apply heat to the affected area.
• B. Apply cold compresses to the affected area.
• C. Use a breast pump to express milk.
• D. Continue breastfeeding as usual.

Correct answer: A

Rationale: The nurse should recommend applying heat to the affected area for a woman with mastitis. Heat can help reduce pain and inflammation associated with mastitis by improving blood flow to the area and promoting healing.

4. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?

• A. Perform a gestational age assessment.
• B. Obtain a drug screen for cocaine.
• C. Determine reactivity of neonatal reflexes.
• D. Weigh and measure the newborn.

Correct answer: B

Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.

5. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant’s head-to-heel length
• B. Observe the infant for sunsetting eyes
• C. Palpate the anterior fontanel for tension and bulging
• D. Plot the measurement on the infant’s growth chart

Correct answer: C

Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.

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