Nursing Elites

1. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

• A. Measure bilirubin levels using transcutaneous bilirubinometry.
• B. Evaluate cord blood Coombs test results.
• C. Review maternal medical records for blood type and Rh factor.
• D. Prepare the newborn for phototherapy.

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

2. What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.

3. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

• A. Weight gain.
• B. Reduction of fever.
• C. Improved caloric intake.
• D. Reduction of edema.

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

4. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?

• A. CO2 combining power
• B. Calcium
• C. Sodium
• D. Chloride

Correct answer: B

Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.

5. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?

• A. Bathe the infant with an antimicrobial soap.
• B. Measure the head and chest circumference.
• C. Obtain the infant's footprints.
• D. Administer vitamin K (AquaMEPHYTON).

Correct answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.

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