Nursing Elites

1. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?

• A. Assess bowel sounds.
• B. Continue to monitor.
• C. Assist with intubation.
• D. Rub the infant's back.

Correct answer: B

Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.

2. Does a blastocyst gain mass only when it receives nourishment from outside?

• A. TRUE
• B. FALSE
• C. Sometimes
• D. Always

Correct answer: A

Rationale: A blastocyst does indeed require external nourishment from the mother's body to continue developing and gaining mass. Without this external nourishment, the blastocyst would not be able to grow and develop properly. Therefore, the statement that a blastocyst gains mass only when it receives nourishment from outside is true. Choices B, C, and D are incorrect because they do not accurately reflect the dependency of a blastocyst on external nourishment for its development and growth.

3. Rico is a man who has enlarged breasts and suffers from mild mental retardation. He has a problem learning languages, and his body produces less of the male sex hormone testosterone than normal males. Rico is most likely suffering from:

• A. Klinefelter syndrome.
• B. Tay-Sachs disease.
• C. Turner syndrome.
• D. Down syndrome.

Correct answer: A

Rationale: Rico's symptoms align with Klinefelter syndrome, which is characterized by an extra X chromosome in males (XXY). Enlarged breasts (gynecomastia), mild mental retardation, learning difficulties, and reduced testosterone production are common features of Klinefelter syndrome. Choice B, Tay-Sachs disease, is a genetic disorder that affects the nervous system and is not associated with the symptoms described. Choice C, Turner syndrome, occurs in females with a missing or partially missing X chromosome and does not fit Rico's profile. Choice D, Down syndrome, is caused by an extra copy of chromosome 21 and typically does not present with the symptoms mentioned for Rico.

4. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?

• A. Administer indomethacin
• B. Insert a second 22-gauge IV catheter.
• C. Insert an indwelling urinary catheter.
• D. Administer oxygen at 4L/min via nasal cannula.

Correct answer: D

Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.

5. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

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