Nursing Elites

1. When assessing a 30-year-old female who was sexually assaulted, what is the MOST important action for you to take?

• A. Have a female healthcare provider perform the assessment.
• B. Advise against showering or changing clothes.
• C. Acknowledge that the patient is a potential crime scene.
• D. Ensure that all life-threatening injuries are treated.

Correct answer: D

Rationale: In cases of sexual assault, the priority is to address any life-threatening injuries first before proceeding with other aspects of care. Although preserving evidence and approaching the situation with sensitivity are crucial, immediate treatment of life-threatening conditions takes precedence to ensure the patient's well-being and safety. Having a female healthcare provider, advising against showering or changing clothes, and acknowledging the patient as a potential crime scene are important but secondary considerations compared to addressing any life-threatening injuries promptly.

2. The healthcare provider assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The healthcare provider documents this finding to be which of the following?

• A. A normal position
• B. A possible chromosomal abnormality
• C. Facial paralysis
• D. Prematurity

Correct answer: A

Rationale: When the top of the ear (pinna) is parallel to the outer and inner canthus of the eye, it is considered a normal position in a newborn. This alignment is an important assessment to ensure normal development and anatomy. Choices B, C, and D are incorrect because the parallel alignment of the ears to the outer and inner canthus of the eye is not indicative of a possible chromosomal abnormality, facial paralysis, or prematurity. It is simply a normal anatomical finding in a newborn.

3. What characteristic indicates that a mass on a newborn's head is a cephalohematoma?

• A. The mass appears on the second day after birth.
• B. The mass grows larger when the newborn cries.
• C. The head appears asymmetrical.
• D. The mass is located on only one side of the head.

Correct answer: A

Rationale: A cephalohematoma typically appears between the first and second days after birth, making choice A the correct answer. It results from blood vessel rupture between a cranial bone and the periosteal membrane. Choices B, C, and D are incorrect because the growth of the mass when the newborn cries, asymmetrical head appearance, or the mass being located on only one side of the head are not specific indicators of a cephalohematoma.

4. A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long?

• A. 2 months
• B. 2 weeks
• C. 1 year
• D. 4 months

Correct answer: D

Rationale: Transient strabismus, causing the baby to look cross-eyed, is due to poor neuromuscular control of the eye muscles. This condition typically resolves on its own within 3 to 4 months as the infant's neuromuscular control improves. Parents should be reassured that this is a common and temporary issue in infants. Choice A is incorrect as it is too long for the resolution of transient strabismus. Choice B is incorrect as 2 weeks is too short for resolution. Choice C is incorrect as 1 year is too long for transient strabismus to resolve.

5. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

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