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. 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.

3. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

• A. The thyroxine level is low because the TSH level is high.
• B. High thyroxine levels do not normally occur in breastfeeding infants.
• C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
• D. The TSH is high because of the low production of T4 by the thyroid.

Correct answer: D

Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.

4. A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?

• A. Encourage the parents to report this to the healthcare provider.
• B. Acknowledge the parents' observation.
• C. Schedule the newborn for further neurological testing.
• D. Explain the newborn’s normal stepping reflex.

Correct answer: D

Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.

5. The client is 24 hours postpartum and is being discharged. The nurse explains that vaginal discharge will change from red to pink and then to white. If the client starts having red bleeding after the color changes, what should the nurse instruct the client to do?

• A. Reduce activity level and notify the healthcare provider.
• B. Go to bed and assume a knee-chest position.
• C. Massage the uterus and go to the emergency room.
• D. Do not worry as this is a normal occurrence.

Correct answer: A

Rationale: If the client experiences red bleeding after the color changes, it may indicate possible hemorrhage or retained placental fragments, which require immediate attention. Instructing the client to reduce activity level and notify the healthcare provider is crucial for prompt evaluation and management of potential complications.

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