Nursing Elites

1. In a case where a limb is protruding from a mother's vagina during active labor, how should this condition be managed?

• A. Positioning the mother in a semi-Fowler's position, administering oxygen, and providing transport
• B. Positioning the mother in a head-down position with her hips elevated, administering oxygen, and providing transport
• C. Applying gentle traction to the protruding limb to remove pressure of the fetus from the umbilical cord
• D. Giving the mother 100% oxygen and attempting to manipulate the protruding limb so that delivery can occur

Correct answer: B

Rationale: When a limb is protruding from the vagina during active labor, the appropriate management includes positioning the mother in a head-down position with her hips elevated. This position helps relieve pressure on the umbilical cord, reducing the risk of compromising fetal blood flow and oxygenation. Administering oxygen is essential to maintain oxygenation levels for both the mother and the fetus. Providing transport to a healthcare facility equipped to manage this obstetric emergency is crucial for ensuring a safe delivery. Choice A is incorrect because a semi-Fowler's position does not effectively relieve pressure on the umbilical cord. Choice C is incorrect as applying traction to the protruding limb can lead to injury or complications for both the mother and the fetus. Choice D is incorrect because attempting to manipulate the limb without proper positioning and preparation can worsen the situation and increase risks during delivery.

2. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

• A. Projectile vomiting
• B. Diarrhea
• C. Constipation
• D. Abdominal distension

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

3. A child with a diagnosis of sickle cell anemia is experiencing a vaso-occlusive crisis. What is the most important nursing intervention?

• A. Administering oxygen
• B. Administering pain medication
• C. Monitoring fluid intake
• D. Encouraging physical activity

Correct answer: B

Rationale: Administering pain medication is the most crucial nursing intervention during a vaso-occlusive crisis in sickle cell anemia. Pain management is a priority to alleviate the patient's discomfort and improve outcomes. Administering oxygen may be necessary in some cases but is not the primary intervention for vaso-occlusive crisis. Monitoring fluid intake is important in sickle cell anemia but is not the priority during a crisis situation. Encouraging physical activity is contraindicated during a vaso-occlusive crisis as it can exacerbate pain and complications.

4. A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?

• A. Administer activated charcoal
• B. Induce vomiting immediately
• C. Call the poison control center
• D. Take the child to the emergency department

Correct answer: C

Rationale: In the case of a child ingesting household bleach, the primary advice should be to call the poison control center (Choice C). The poison control center can provide specific guidance on how to manage the ingestion, including whether any immediate interventions are necessary. Administering activated charcoal (Choice A) or inducing vomiting immediately (Choice B) can worsen the situation as they are not recommended treatments for bleach ingestion. Taking the child to the emergency department (Choice D) may be necessary depending on the advice given by the poison control center, but the initial step should be to seek guidance from the experts at the poison control center.

5. When teaching parents about preventing childhood obesity, what should the nurse recommend?

• A. Encourage high-calorie snacks
• B. Limit screen time
• C. Encourage fast food as a treat
• D. Allow the child to eat freely

Correct answer: B

Rationale: Limiting screen time is a crucial recommendation to prevent childhood obesity. Excessive screen time is associated with sedentary behavior and increased consumption of unhealthy snacks, leading to weight gain. Encouraging high-calorie snacks (Choice A) contradicts the goal of preventing obesity. While fast food as a treat (Choice C) can be consumed occasionally, it should not be encouraged as a regular practice. Allowing the child to eat freely (Choice D) without restrictions can lead to overeating and unhealthy dietary habits, contributing to obesity risk.

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