Nursing Elites

1. Which of the following is an abnormal finding when assessing the abdomen of a newborn?

• A. The umbilical cord has two arteries and one vein.
• B. The presence of green vomit.
• C. The liver is palpable 1 to 2 cm below the costal margin.
• D. The abdomen is soft and nondistended.

Correct answer: B

Rationale: The correct answer is B. The presence of green vomit in a newborn is an abnormal finding and indicates a possible intestinal obstruction. This finding requires immediate attention and further investigation. Choices A, C, and D are normal findings in a newborn's abdomen assessment. A newborn typically has an umbilical cord with two arteries and one vein, a liver that may be palpable 1 to 2 cm below the costal margin due to its normal size in a neonate, and a soft, nondistended abdomen as expected in healthy newborns.

2. A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect:

• A. croup.
• B. foreign body airway obstruction.
• C. lower respiratory infection.
• D. epiglottitis.

Correct answer: B

Rationale: In a 3-year-old child with a sudden onset of respiratory distress and no recent illnesses or fever, the likely cause is a foreign body airway obstruction. Foreign body obstruction can lead to sudden respiratory distress without other preceding symptoms. It is crucial to consider this possibility and act promptly to clear the airway in such cases to prevent serious complications.

3. A postpartum client is concerned about hair loss. The nurse explains that this is:

• A. A sign of nutritional deficiency
• B. A temporary condition due to hormonal changes
• C. An indication of a thyroid disorder
• D. A result of poor hair care during pregnancy

Correct answer: B

Rationale: Hair loss postpartum is a common temporary condition caused by hormonal changes that occur after giving birth. This condition is known as postpartum alopecia and is a normal part of the postpartum period. It is important for the nurse to reassure the client that this hair loss is temporary and usually resolves on its own without the need for medical intervention. Choice A is incorrect because postpartum hair loss is primarily due to hormonal changes rather than nutritional deficiency. Choice C is incorrect as thyroid disorder is not typically the cause of postpartum hair loss. Choice D is incorrect as poor hair care during pregnancy does not cause postpartum hair loss.

4. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. In addition to administering high-flow oxygen, treatment should include:

• A. treating for shock and uterine massage during transport.
• B. uterine massage and transport.
• C. placing her on her left side and transport.
• D. internal vaginal pads and treating for shock during transport.

Correct answer: A

Rationale: In this scenario, the mother is showing signs of postpartum hemorrhage with increased heart rate, diaphoresis, and mild vaginal bleeding. The correct approach involves treating for shock by addressing hypovolemia and providing uterine massage to help control bleeding. Administering high-flow oxygen is essential. Therefore, the most appropriate option is to treat for shock and perform uterine massage during transport to manage the postpartum hemorrhage effectively.

5. When working with a new adolescent patient, which greeting by the nurse indicates awareness of the needs of the adolescent client?

• A. I will talk with your parents first, and then you can tell me why you are here.
• B. Please let me know what your concerns are, and if you have any questions.
• C. Before we begin, I will need to know if you are sexually active.
• D. I will do the physical exam first, and then we will talk about your history.

Correct answer: B

Rationale: The greeting 'Please let me know what your concerns are, and if you have any questions.' indicates awareness of the needs of the adolescent client. It encourages open communication, allows the adolescent to voice their concerns, and shows that their questions are welcomed and valued, fostering a trusting nurse-patient relationship. Choices A, C, and D do not prioritize the adolescent's perspective or promote open communication. Asking to talk to the parents first (Choice A) may hinder the adolescent's autonomy and trust. Inquiring about sexual activity (Choice C) may be necessary but should be approached with sensitivity and privacy. Doing the physical exam first (Choice D) before discussing the patient's history may not align with the adolescent's need for communication and understanding.

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