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 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.

3. A 1-month-old girl with low-set ears and severe hypotonia has been diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

• A. Interrupted family process related to the child's diagnosis
• B. Deficient knowledge related to the genetic disorder
• C. Grieving related to the child's poor prognosis
• D. Ineffective coping related to the stress of providing care

Correct answer: C

Rationale: The most likely nursing diagnosis for a 1-month-old girl with trisomy 18, characterized by low-set ears and severe hypotonia, is 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience grief as they come to terms with the challenges and uncertainties associated with the condition. 'Interrupted family process' may not be as relevant since the primary focus is on the child's condition. 'Deficient knowledge related to the genetic disorder' could be important but may not be the most likely initial concern, as emotional support for the family is crucial at this point. 'Ineffective coping related to the stress of providing care' is a broad diagnosis that does not specifically address the emotional response to the child's prognosis, which is the primary concern in this case.

4. 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.

5. The child has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management?

• A. Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered.
• B. Use guided imagery and therapeutic touch.
• C. Administer meperidine as ordered.
• D. Initiate pain assessment with a standardized pain scale.

Correct answer: D

Rationale: Initiating pain assessment with a standardized pain scale is crucial in managing pain effectively during a sickle cell crisis. This step allows the nurse to objectively evaluate the child's pain level and tailor the pain management plan accordingly. Administering medication without a proper assessment could lead to inappropriate pain management. Using guided imagery and therapeutic touch may be beneficial as adjunct therapies but should not replace the initial pain assessment. Meperidine is not typically the first-line choice for pain management in sickle cell crisis due to its potential for neurotoxic metabolites.

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