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. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

• A. A client with a urinary output of 300 ml in 8 hours
• B. A client reporting abdominal cramping during breastfeeding
• C. A client receiving magnesium sulfate with absent deep tendon reflexes
• D. A client reporting lochia rubra requiring changing perineal pads every 3 hours

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

3. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

• A. Membranes are intact.
• B. 2+ pitting edema in lower extremities.
• C. Contractions decrease with walking.
• D. Cervical dilation is 1 centimeter.

Correct answer: C

Rationale: The correct answer is C. Contractions that decrease with walking are typically indicative of false labor, as true labor contractions tend to intensify with activity. Choices A, B, and D are incorrect. A) Intact membranes are a normal finding and do not confirm the absence of labor. B) 2+ pitting edema in lower extremities is a sign of fluid retention and not directly related to labor status. D) Cervical dilation of 1 centimeter indicates some cervical changes, but it alone does not confirm active labor.

4. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?

• A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
• B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
• C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
• D. Record the findings on the chart. They are within normal limits.

Correct answer: D

Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.

5. Chromosomes contain thousands of segments called:

• A. nuclei.
• B. nodes.
• C. capillaries.
• D. genes.

Correct answer: D

Rationale: Chromosomes are structures composed of DNA and genes. Genes are the functional segments within chromosomes that encode specific traits and characteristics. The other choices ('nuclei,' 'nodes,' 'capillaries') do not accurately describe the segments found within chromosomes and are unrelated to their structure or function.

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