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. At 20 weeks gestation, a client is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

• A. Sex and size of the fetus.
• B. Chromosomal abnormalities.
• C. Fetal growth and gestational age.
• D. Lecithin-sphingomyelin ratio.

Correct answer: C

Rationale: The primary reason for an ultrasound at 20 weeks gestation is to assess fetal growth, gestational age, and anatomical development. This evaluation helps ensure the fetus is developing appropriately and can detect any potential issues that may require intervention. Choices A, B, and D are incorrect because at 20 weeks, the primary focus of the ultrasound is not to determine the sex of the fetus, detect chromosomal abnormalities, or assess the lecithin-sphingomyelin ratio. While these factors may be evaluated in pregnancy, they are not the primary reasons for an ultrasound at 20 weeks gestation.

3. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

• A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
• B. Count the movements once daily, for one hour, before breakfast.
• C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
• D. Exercise for 15 minutes before starting the counting to help increase fetal movement.

Correct answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

4. Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?

• A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
• B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
• C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
• D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Correct answer: D

Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.

5. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

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