Nursing Elites

1. What maternal behavior is typically observed when a new mother first receives her infant?

• A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
• B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
• C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
• D. She eagerly reaches for the infant and then holds the infant close to her own body.

Correct answer: B

Rationale: When a new mother first receives her infant, a typical maternal behavior is to use her arms and hands to receive the infant and then trace the infant's profile with her fingertips. This action is a gentle way of bonding with the newborn and aids in recognizing the infant's features. Choices A, C, and D are incorrect as they do not accurately describe the common behavior of tracing the infant's profile, which is a significant part of the initial interaction between a mother and her newborn.

2. After two miscarriages, a client is instructed to increase her daily intake of foods that include folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

• A. Strawberries.
• B. Yogurt.
• C. Collard greens.
• D. Whole milk.

Correct answer: C

Rationale: Collard greens are a good source of folic acid, which is important for preventing neural tube defects, especially in clients with a history of miscarriages. Since the client does not like green leafy vegetables, collard greens could be suggested as an alternative source of folic acid. Yogurt and whole milk do not contain significant amounts of folic acid, and while strawberries are a healthy choice, they are not a high source of folic acid compared to collard greens.

3. A client at 28 weeks gestation calls the antepartum clinic and reports experiencing a small amount of bright red vaginal bleeding without uterine contractions or abdominal pain. What instruction should the LPN/LVN provide?

• A. Come to the clinic today for an ultrasound.
• B. Go immediately to the emergency room.
• C. Lie on your left side for about one hour and see if the bleeding stops.
• D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

Correct answer: A

Rationale: Bright red vaginal bleeding without pain could indicate placental issues such as previa. An ultrasound is necessary to evaluate the cause. It is important to rule out potential serious conditions like placental previa, which can lead to further complications for both the mother and the fetus. Therefore, prompt evaluation through an ultrasound at the clinic is essential for appropriate management and ensuring the well-being of the client and her baby.

4. A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?

• A. Refer the mother to the Centers for Disease Control and Prevention.
• B. Report the incident to the school principal.
• C. Culture the bite site when the child returns to school.
• D. Schedule a test for Lyme disease if a rash appears.

Correct answer: D

Rationale: The correct action to take in this situation is to schedule a test for Lyme disease if a rash appears. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom of the disease. Testing for Lyme disease is crucial for timely diagnosis and treatment to prevent complications. Referring the mother to the Centers for Disease Control and Prevention (Choice A) is not necessary at this point, as immediate testing for Lyme disease is more appropriate. Reporting the incident to the school principal (Choice B) is not the most direct action to address the potential health concern. Culturing the bite site when the child returns to school (Choice C) may not be as effective as scheduling a test for Lyme disease if a rash appears, as the latter is a more specific diagnostic measure for Lyme disease.

5. When should the LPN/LVN encourage the laboring client to begin pushing?

• A. When there is only an anterior or posterior lip of the cervix left.
• B. When the client describes the need to have a bowel movement.
• C. When the cervix is completely dilated.
• D. When the cervix is completely effaced.

Correct answer: C

Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal. Choices A, B, and D are incorrect because pushing before complete dilation can be harmful and may not effectively help in the descent of the baby. The presence of an anterior or posterior lip of the cervix, the urge to have a bowel movement, or complete effacement of the cervix are not indicators for the initiation of pushing during labor.

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