Nursing Elites

1. The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?

• A. Lanugo mostly gone, little vernix remaining on the body
• B. Prominent clitoris, enlarging labia minora, patent anus
• C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
• D. Skin opaque, cracking at wrists and ankles, no visible vessels

Correct answer: B

Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.

2. In educating the parents of a child diagnosed with hypothyroidism, the nurse mentions that the child should avoid goitrogens. Which of the following will the nurse mention as an example?

• A. Orange
• B. Tomatoes
• C. Cabbage
• D. Grapes

Correct answer: C

Rationale: Cabbage is an example of a goitrogen that should be avoided in children with hypothyroidism. Goitrogens are substances that can interfere with thyroid function by inhibiting iodine uptake, potentially worsening the condition. Cabbage, along with other cruciferous vegetables like broccoli and cauliflower, contains compounds that can affect thyroid hormone production. Oranges, tomatoes, and grapes are not classified as goitrogens. Therefore, it is important for parents to be aware of foods like cabbage and to limit their child's intake to help manage their hypothyroidism effectively.

3. Beta-adrenergic agonists such as albuterol are given to Reggie, a child with asthma, to primarily do which of the following?

• A. Dilate the bronchioles
• B. Reduce secondary infections
• C. Decrease postnasal drip
• D. Reduce airway inflammation

Correct answer: A

Rationale: Beta-adrenergic agonists like albuterol are bronchodilators that primarily work by relaxing and dilating the bronchioles, which helps to alleviate bronchoconstriction, a characteristic feature of asthma. This action leads to improved airflow and easier breathing for individuals experiencing asthma symptoms.

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. The mother of an 11-year-old girl confides to the nurse that her child has no interest in school activities, exercise, or even family outings. The most appropriate response by the nurse would be:

• A. I would recommend that she see a counselor at school.
• B. I would not worry; she will grow out of it.
• C. Many girls this age go through a time of malaise and disinterest.
• D. If she still feels the same way when you come back for the next well-child visit, I will recommend a therapist.

Correct answer: A

Rationale: When a child shows a lack of interest in various activities, including school, exercise, and family outings, it is essential to address the underlying reasons. Recommending that the child see a counselor at school is crucial to explore potential issues and provide appropriate support and guidance. This approach can help identify any emotional, social, or behavioral concerns the child may be experiencing and facilitate early intervention and support. Choice B is incorrect because dismissing the mother's concerns and assuming the child will grow out of it without addressing the issue is not appropriate. Choice C is incorrect because while some children may go through phases of disinterest, it is essential to investigate further rather than generalizing. Choice D is incorrect because waiting until the next visit without taking proactive steps to address the current lack of interest may delay necessary support and intervention.

Similar Questions