Nursing Elites

1. You and your partner are performing CPR on a 2-year-old female in cardiac arrest. During your resuscitation attempt, you should:

• A. hyperventilate her due to severe hypoxia.
• B. attach the AED pads after 5 minutes of high-quality CPR.
• C. perform compressions and ventilations at a ratio of 30:2.
• D. allow the chest to fully recoil between compressions.

Correct answer: D

Rationale: Allowing the chest to fully recoil between compressions is crucial during CPR to ensure proper blood flow. This action allows the heart to refill with blood, enhancing the effectiveness of compressions and circulation. Hyperventilating the patient can lead to decreased cardiac output and is not recommended. Attaching AED pads should be done as soon as possible in a pediatric cardiac arrest situation, ideally within 2 minutes. The correct compression-to-ventilation ratio for pediatric CPR is 30:2, focusing on high-quality compressions to provide adequate perfusion to vital organs.

2. The healthcare provider is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

• A. (+) Moro reflex
• B. Heart rate is 80 bpm
• C. Respirations are irregular
• D. Uneven head shape

Correct answer: B

Rationale: A heart rate of 80 bpm is least likely to be observed in a normal newborn. The normal heart rate range for a newborn is usually higher than 80 bpm, typically ranging from 120-160 bpm. The Moro reflex (choice A) is a normal newborn reflex, respirations being irregular (choice C) are expected due to the immature respiratory control center, and an uneven head shape (choice D) is common due to molding during vaginal delivery.

3. When using the Ballard gestational assessment tool on a newborn, which of the following tests should be performed after the first hour of birth, allowing the newborn to recover from the stress of birth?

• A. Arm recoil
• B. Square window sign
• C. Scarf sign
• D. Popliteal angle

Correct answer: A

Rationale: The correct answer is Arm recoil. Arm recoil is slower in healthy but fatigued newborns after birth, making it best elicited after the first hour of birth when the baby has had time to recover from the stress of birth. This assessment helps evaluate neuromuscular maturity in newborns and is more accurate when performed after the initial recovery period. The other choices, Square window sign, Scarf sign, and Popliteal angle, are not specifically assessed using the Ballard gestational assessment tool and do not relate to the recovery period after birth.

4. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?

• A. Fluid intake should double the urine output
• B. Fluid intake should be approximately equal to the urine output
• C. Fluid intake should be half the urine output
• D. Fluid intake should be inversely proportional to the urine output

Correct answer: B

Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.

5. What comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?

• A. He is always hungry.
• B. He tires out during feedings.
• C. He is fussy for several hours every day.
• D. He sleeps all the time.

Correct answer: B

Rationale: Observing a 1-month-old tiring out during feedings should alert the nurse to the possibility of a congenital heart defect. This symptom may indicate that the infant is expending excess energy to compensate for a heart issue, leading to fatigue during feeding. Choices A, C, and D do not directly relate to a congenital heart defect. Being always hungry, fussy, or sleeping a lot are not specific signs of a congenital heart defect in a 1-month-old.

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