Nursing Elites

1. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:

• A. Prevent eye infection.
• B. Dilate the pupil so the red reflex can be visualized.
• C. Clear the infant's vision.
• D. Prevent herpes infection.

Correct answer: A

Rationale: The correct answer is A: Prevent eye infection. Eye ointment, usually containing erythromycin, is applied to prevent neonatal conjunctivitis, which can be caused by bacteria present in the birth canal. It is not used to dilate the pupil, clear the infant's vision, or prevent herpes infection.

2. The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

• A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
• B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
• C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
• D. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.

Correct answer: B

Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.

3. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

4. Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?

• A. Swaddle the infant in a warm blanket.
• B. Obtain a heel stick blood glucose level.
• C. Place a pulse oximeter on the heel.
• D. Document the findings in the record.

Correct answer: B

Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.

5. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

• A. Provide information about the high-risk nature of her pregnancy.
• B. Gently remind the client that anti-rejection drugs can cause sterility.
• C. Explain the benefits of waiting for a five-year post-transplant period.
• D. Determine if the client is considering options for adopting a child.

Correct answer: A

Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.

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