Nursing Elites

1. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

• A. Administer oxygen by mouth at 2L/min
• B. Gradually warm the infant under a radiant heat source
• C. Notify the pediatrician of the infant's vital signs
• D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

2. During the client’s initial prenatal visit, which of the following would indicate a need for further assessment?

• A. History of diabetes for 6 years.
• B. Exercises three times a week.
• C. Occasional use of over-the-counter pain relievers.
• D. Maternal age 30 years.

Correct answer: A

Rationale: A history of diabetes for 6 years indicates a pre-existing medical condition that can significantly impact both the mother and the developing fetus during pregnancy. This necessitates further assessment and monitoring to manage potential complications. Regular exercise (Choice B) is generally beneficial during pregnancy and does not raise immediate concerns. Occasional use of over-the-counter pain relievers (Choice C) is common and does not necessarily indicate a need for further assessment during the initial visit. Maternal age of 30 years (Choice D) falls within the normal range for childbearing and is not a standalone factor requiring immediate further assessment.

3. The client who is 40 weeks gestation seems upset and tells the nurse that the physician told her she needs to have a nonstress test. The client asks why she needs the test. The nurse’s best response would be:

• A. This is a test to see if your stress level is affecting your baby’s growth and well-being.
• B. This is a test to see if your baby will be able to withstand the stress of labor.
• C. This is a test to assess your baby’s well-being now that you are due to deliver soon.
• D. This is a test to let us know if your baby needs to be delivered to avoid a bad outcome.

Correct answer: C

Rationale: The correct response is C because the nonstress test is specifically used to assess the baby's well-being close to the due date. It helps determine if the baby is receiving enough oxygen and nutrients in the womb. Choice A is incorrect as the test does not assess the mother's stress level but focuses on fetal well-being. Choice B is incorrect as the test does not predict the baby's ability to withstand labor. Choice D is incorrect because the test does not solely indicate if the baby needs to be delivered to avoid a bad outcome; rather, it assesses the current well-being of the baby.

4. A nurse is planning to teach a group of clients who are breastfeeding after returning to work. Which of the following instructions should the nurse include in the teaching?

• A. “Thawed breast milk can be refrigerated for up to 24 hours.”
• B. “Breast milk can be stored in a deep freezer for 12 months.”
• C. “Breast milk can be stored at room temperature for up to 4 hours.”
• D. “Thawed breast milk that is unused cannot be refrozen.”

Correct answer: B

Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This instruction is important for mothers returning to work to ensure a long-term storage option for breast milk. Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator. Choice C is incorrect as breast milk can be kept at room temperature for only up to 4 hours. Choice D is incorrect as thawed breast milk that is unused should not be refrozen due to safety concerns.

5. Does the probability of having a child with Down’s syndrome increase with the age of the parents?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Never

Correct answer: A

Rationale: The correct answer is A: TRUE. Advanced parental age, particularly maternal age, is associated with an increased risk of Down's syndrome in offspring. As parents get older, the likelihood of having a child with Down's syndrome increases. Choices B, C, and D are incorrect because the risk of Down's syndrome is known to rise with parental age, especially maternal age, due to the increased likelihood of chromosomal abnormalities during egg formation.

Similar Questions