Nursing Elites

1. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

• A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
• B. Remove restraints one at a time to provide range of motion exercises.
• C. Record observation of the restraints q2h and ensure that they are in place at all times.
• D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

2. A client addicted to heroin and newly pregnant asks a nurse about ensuring her baby's health while on methadone. What should the nurse advise?

• A. Sign up for group therapy sessions.
• B. Discontinue the methadone right away.
• C. Start prenatal care as soon as possible.
• D. Describe genetic testing protocol.

Correct answer: C

Rationale: Initiating prenatal care promptly is essential for monitoring the well-being of both the mother and the fetus, particularly in high-risk pregnancies involving substance use. Early prenatal care allows for timely interventions, education, and support to promote a healthier pregnancy and birth outcomes. Choice A is incorrect because while group therapy may be beneficial, initiating prenatal care is more crucial at this stage. Choice B is incorrect as abrupt discontinuation of methadone can be harmful and should be managed under medical supervision. Choice D is incorrect as genetic testing is not the immediate priority in this scenario.

3. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

4. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?

• A. Advise the mother to wait at least another month before starting any solid foods.
• B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
• C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
• D. Encourage the mother to schedule a developmental assessment of the infant.

Correct answer: C

Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding. Choice A is incorrect because waiting another month is not necessary if the infant is 6 months old. Choice B is incorrect as introducing pureed fruits as the first food may not provide the necessary iron that the infant needs at this stage. Choice D is also incorrect as scheduling a developmental assessment is not indicated solely based on the desire to start solid foods; it is more appropriate to reassure the mother about starting iron-fortified cereal.

5. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

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