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. A patient has been diagnosed with hypothyroidism; the nurse tells the patient not to eat goitrogens. Which of the following is an example of a goitrogen?

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

Correct answer: C

Rationale: Cabbage is an example of a goitrogen. Goitrogens are substances that can interfere with thyroid function by inhibiting the uptake of iodine. Cabbage contains compounds that can have this effect and should be consumed in moderation by individuals with hypothyroidism.

3. How will a ventricular septal defect affect blood flow?

• A. Blood will shunt left to right, causing increased pulmonary flow and no cyanosis.
• B. Blood will shunt right to left, causing decreased pulmonary flow and cyanosis.
• C. No shunting occurs due to high pressure in the left ventricle.
• D. Increased pressure in the left atrium hinders the circulation of oxygenated blood in the circulating volume.

Correct answer: A

Rationale: A ventricular septal defect allows blood to shunt left to right, leading to increased pulmonary flow. This results in oxygenated blood mixing with deoxygenated blood, causing no cyanosis as the mixed blood is still oxygenated. The shunting from left to right overloads the pulmonary circulation, leading to increased pulmonary flow. Choice B is incorrect because blood does not shunt right to left in a ventricular septal defect. Choice C is incorrect as shunting does occur due to the pressure differences between the ventricles. Choice D is incorrect because the defect affects the ventricles, not the atrium, and does not hinder the circulation of oxygenated blood in the circulating volume.

4. The healthcare provider is assessing 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, known as postpartum hemorrhage, which is a critical condition requiring immediate intervention to prevent further complications like hypovolemic shock. Monitoring and managing postpartum bleeding are crucial in the early postpartum period to ensure the client's safety and well-being. The other options are normal postpartum findings: lochia rubra with a few small clots is expected in the early postpartum period, a firm and midline fundus indicates proper uterine contraction, and a temperature of 100.4°F (38°C) is within the normal range for the postpartum period.

5. What is the appropriate technique for performing two-rescuer CPR on a 4-year-old child?

• A. 15 compressions to 2 ventilations, compressing the sternum with your thumbs, and delivering at least 100 compressions per minute.
• B. 30 compressions to 2 ventilations, compressing the chest one third the depth of the chest, and delivering each breath over 1 second.
• C. 15 compressions to 2 ventilations, compressing the sternum with the heel of your hand, and ventilating until visible chest rise occurs.
• D. 30 compressions to 2 ventilations, compressing the sternum with the heel of both hands, and delivering each breath over 1 to 2 seconds.

Correct answer: C

Rationale: When performing two-rescuer CPR on a 4-year-old child, the appropriate technique involves 15 compressions to 2 ventilations. Compressions should be done by pressing the child's sternum with the heel of your hand. Ventilations should be given until visible chest rise occurs. This technique ensures effective CPR delivery for a child in need of resuscitation.

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