Nursing Elites

1. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?

• A. emotional support to help the family cope with feelings of guilt about the infant's condition
• B. administration of MICRhoGam to the woman within 72 hours of delivery
• C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
• D. lab analysis of maternal Direct Coombs' test

Correct answer: A

Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.

2. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

3. A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information?

• A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician
• B. That the stools should be solid and pale yellow to light brown
• C. That this is normal for breastfed infants
• D. To decrease the number of feedings by two per day

Correct answer: C

Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools, which is considered normal. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. It is essential for the mother to understand that seedy, mustard-yellow stools are expected in breastfed infants, indicating that there is no need for concern. Monitoring for infection as the first response without other symptoms can cause unnecessary anxiety. Decreasing the number of feedings without valid reasons can lead to inadequate nutrition for the newborn. Therefore, the correct advice for the nurse to provide in this scenario is that seedy, mustard-yellow stools are normal for breastfed infants, reassuring the mother and promoting proper understanding of newborn stool characteristics.

4. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously
• B. give the medications sequentially, and flush well between them
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
• D. start one medication now and begin the other medication in 2-4 hours

Correct answer: B

Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.

5. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' If an 11-12-month-old child is unable to pull to a standing position, it can indicate a risk for developmental dysplasia of the hip. By 15 months of age, children should be walking, so delayed standing can be a red flag. The Trendelenburg sign is associated with gluteus medius muscle weakness, not hip dysplasia, making choice C incorrect. The Ortolani sign is used to detect congenital hip subluxation or dislocation, not developmental dysplasia, making choice D incorrect.

Similar Questions