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. What behavior does a toddler subjected to prolonged hospitalization with limited parental visits typically exhibit?

• A. Engage in cheerful interactions with staff members
• B. Display indications of sadness throughout the day
• C. Experience excessive crying when parents are not present
• D. Show limited emotional response to the environment

Correct answer: D

Rationale: Toddlers subjected to prolonged hospitalization with limited parental visits usually exhibit a limited emotional response to the environment. This behavior can be a coping mechanism for the child in dealing with the separation from their primary caregivers. The child might not show the same level of engagement or emotional expression as they would if their parents were present. Choices A, B, and C are less likely because the child's emotional response is typically more subdued and withdrawn in such circumstances, rather than being cheerful, consistently sad, or excessively crying.

3. A parent asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent about rubeola that is different from rubella?

• A. High fever and Koplik spots
• B. Rash on the trunk with pruritus
• C. Nausea, vomiting, and abdominal cramps
• D. Characteristics of a cold, followed by a rash

Correct answer: A

Rationale: The correct answer is A: 'High fever and Koplik spots.' Rubeola (measles) is characterized by a high fever and the presence of Koplik spots, which are not seen in rubella (German measles). Choice B, rash on the trunk with pruritus, is more indicative of rubella. Choice C, nausea, vomiting, and abdominal cramps, are not specific to either rubeola or rubella. Choice D, characteristics of a cold followed by a rash, is not a typical presentation of rubeola or rubella.

4. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?

• A. Risk for injury related to malignant process and treatment
• B. Fluid volume deficit related to excessive losses
• C. Fluid volume excess related to decreased plasma filtration
• D. Fluid volume excess related to fluid accumulation in tissues and third spaces

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is fluid volume excess related to decreased plasma filtration. Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than fluid deficit (choice B) or fluid accumulation in tissues and third spaces (choice D). The diagnosis of 'risk for injury related to malignant process and treatment' (choice A) is not directly related to the pathophysiology of acute glomerulonephritis.

5. The healthcare provider notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of

• A. poor appetite
• B. increased potassium intake
• C. reduction of edema
• D. restriction to bed rest

Correct answer: C

Rationale: In acute glomerulonephritis, weight loss is most likely due to the reduction of edema. Edema is a common symptom of glomerulonephritis, which causes fluid retention and swelling in the body. As treatment progresses and the condition improves, the reduction of edema leads to weight loss. Choices A, B, and D are incorrect as they do not directly address the underlying pathophysiology of acute glomerulonephritis and its impact on weight loss.

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