Nursing Elites

1. After a mother was diagnosed with gonorrhea immediately after delivery, what is an important goal of the nurse when providing care for her baby?

• A. Prevent the development of ophthalmia neonatorum.
• B. Lubricate the eyes.
• C. Prevent the development of infection.
• D. Teach about the risks of breastfeeding with gonorrhea.

Correct answer: A

Rationale: The correct answer is A: Prevent the development of ophthalmia neonatorum. When a mother has gonorrhea, the baby can be infected during delivery, leading to ophthalmia neonatorum, which can cause permanent blindness. Therefore, it is crucial for the nurse to prevent this condition by treating the baby's eyes with an antibiotic prophylactically after birth. Choice B, lubricating the eyes, is not the primary goal in this situation as preventing infection takes precedence. Choice C, preventing the development of infection, is too broad and does not specifically address the potential complication of ophthalmia neonatorum. Choice D, teaching about the risks of breastfeeding with gonorrhea, is important but not the immediate goal in this scenario where preventing ophthalmia neonatorum and potential blindness is the priority.

2. A healthcare provider is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the provider include in the teaching?

• A. Hepatitis B
• B. Rotavirus
• C. Pneumococcal
• D. Varicella

Correct answer: A

Rationale: The correct answer is Hepatitis B. Newborns receive the Hepatitis B vaccine shortly after birth to provide protection against the virus. Rotavirus, Pneumococcal, and Varicella vaccines are typically administered at later stages of infancy or childhood, not immediately after birth. Rotavirus vaccine helps prevent severe diarrhea, Pneumococcal vaccine protects against infections like pneumonia and meningitis, and Varicella vaccine prevents chickenpox. However, these vaccines are not part of the routine immunizations given to newborns immediately after birth.

3. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?

• A. Caput succedaneum
• B. Hydrocephalus
• C. Cephalhematoma
• D. Microcephaly

Correct answer: C

Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.

4. The nurse is caring for a multiparous client who is 8 centimeters dilated, 100% effaced, and the fetal head is at 0 station. The client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement?

• A. Administer IV pain medication
• B. Perform a vaginal exam
• C. Reposition to side-lying
• D. Encourage pushing with each contraction

Correct answer: C

Rationale: Repositioning the client to a side-lying position is the most appropriate intervention in this scenario. This position can help relieve pressure on the cervix and reduce the urge to push prematurely, allowing the cervix to continue dilating. Administering IV pain medication may not address the underlying cause of the discomfort, and pushing prematurely can lead to cervical trauma. Performing a vaginal exam is not necessary at this point as the client is already 8 centimeters dilated, and the fetal head is at 0 station.

5. Jill bears the genetic code for Von Willebrand disease, but she has never developed the illness herself. Jill would be considered:

• A. a carrier of the recessive gene that causes the disease.
• B. susceptible to the disease after adolescence.
• C. an acceptor of the recessive gene that causes the disease.
• D. susceptible to the disease in late adulthood.

Correct answer: A

Rationale: Jill is a carrier of the recessive gene for Von Willebrand disease. Being a carrier means that she has one copy of the gene but does not show symptoms of the disease. Carriers can pass on the gene to their offspring. Choice B is incorrect as being a carrier does not mean she is susceptible to developing the disease after adolescence. Choice C is incorrect as 'acceptor' is not a term used in genetics in this context. Choice D is incorrect as susceptibility to the disease is not related to late adulthood in carriers of a recessive gene.

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