Nursing Elites

1. Which of the following clinical signs would MOST suggest acute respiratory distress in a 2-month-old infant?

• A. Heart rate of 130 beats/min
• B. Respiratory rate of 30 breaths/min
• C. Abdominal breathing
• D. Grunting respirations

Correct answer: D

Rationale: Grunting respirations are a key clinical sign of acute respiratory distress in infants. Grunting is a protective mechanism where the infant exhales against a partially closed glottis to increase functional residual capacity and oxygenation. This is often seen in conditions such as respiratory distress syndrome, pneumonia, or other causes of respiratory compromise in infants. Monitoring respiratory patterns like grunting is crucial for early recognition and intervention in infants with respiratory distress. Choices A, B, and C are less specific to acute respiratory distress in infants. While an elevated heart rate and respiratory rate can be present in respiratory distress, grunting respirations are a more direct indicator of significant respiratory compromise in infants.

2. In the treatment of an infected hematoma, which of the following is NOT recommended?

• A. Incision and drainage
• B. Systemic antibiotics
• C. A and B
• D. Vitamin E

Correct answer: D

Rationale: Vitamin E is not a standard treatment for infected hematomas. The primary interventions for infected hematomas typically involve incision and drainage to remove infected fluid and debris, along with the administration of systemic antibiotics to combat the infection. Vitamin E does not play a significant role in the treatment of infected hematomas and is therefore not recommended as a primary treatment option. Choice A (Incision and drainage) and Choice B (Systemic antibiotics) are recommended treatments for infected hematomas as they help in removing infected fluid and combating the infection, respectively. Therefore, the correct answer is D, Vitamin E.

3. Non-pharmacological techniques can help lower blood pressure. Which of the following is not considered one of these types of techniques?

• A. Dietary changes
• B. Multivitamins
• C. Smoking cessation
• D. Limiting caffeine

Correct answer: B

Rationale: Multivitamins are not typically considered a non-pharmacological technique for lowering blood pressure. While dietary changes, smoking cessation, and limiting caffeine intake can positively impact blood pressure levels, multivitamins are generally not specifically recommended as a primary intervention for this purpose. Dietary changes can include reducing salt intake and increasing potassium-rich foods, which are known to help manage blood pressure. Smoking cessation is crucial due to the negative impact of smoking on blood pressure and overall cardiovascular health. Limiting caffeine intake is advised as excessive caffeine consumption can lead to a temporary increase in blood pressure. Therefore, focusing on lifestyle modifications like healthy eating, smoking cessation, and caffeine reduction is more effective in managing blood pressure than relying on multivitamins.

4. Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

• A. Amount and area of vernix coverage
• B. Creases on the sole
• C. Size of the areola
• D. Body surface temperature

Correct answer: A

Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.

5. A postpartum client asks the nurse about resuming sexual activity. What is the nurse's best response?

• A. You can resume sexual activity as soon as you feel ready.
• B. It is best to wait until your postpartum check-up before resuming sexual activity.
• C. You should wait at least 6 weeks before resuming sexual activity.
• D. It is safe to resume sexual activity once your lochia has stopped.

Correct answer: B

Rationale: The best response for the nurse is to advise the postpartum client to wait until the postpartum check-up before resuming sexual activity. This allows for complete healing to ensure the client's well-being and provides an opportunity to address any concerns with the healthcare provider. Choice A is incorrect because resuming sexual activity should be based on medical advice rather than personal readiness. Choice C is incorrect as the 6-week recommendation is a general guideline but individual circumstances may vary. Choice D is incorrect as the cessation of lochia is not the sole indicator for safe resumption of sexual activity.

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