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. _________ are problems that stem from the interaction of heredity and environmental factors.

• A. Multifactorial problems
• B. Cognitive problems
• C. Horizon problems
• D. Coronal problems

Correct answer: A

Rationale: Multifactorial problems are conditions that result from the interplay of genetic and environmental factors. These conditions, such as diabetes or heart disease, are not solely determined by genetics or environment but are influenced by a combination of both factors. Choice B, cognitive problems, refers to difficulties related to thinking, learning, and memory and are not specifically linked to genetic and environmental interactions. Choices C and D, horizon problems and coronal problems, are nonsensical terms and do not relate to the interaction of heredity and environmental factors.

3. What maternal factor should the nurse identify as having the greatest impact on the development of spina bifida occulta in a newborn?

• A. Short interval between pregnancies
• B. Folic acid deficiency
• C. Preeclampsia
• D. Tobacco use

Correct answer: B

Rationale: Folic acid deficiency during pregnancy is a well-known risk factor for neural tube defects, including spina bifida occulta, making supplementation critical in prenatal care. Folic acid plays a crucial role in neural tube formation during early pregnancy. Short intervals between pregnancies do not directly impact the development of spina bifida occulta. Preeclampsia is a hypertensive disorder of pregnancy and is not directly linked to spina bifida occulta. While tobacco use during pregnancy has various adverse effects, it is not the primary factor influencing the development of spina bifida occulta in newborns.

4. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?

• A. Tinnitus
• B. Urinary Frequency
• C. Breast Tenderness
• D. Chills

Correct answer: C

Rationale: The correct answer is C: 'Breast Tenderness.' Clomiphene citrate is known to cause breast tenderness as a common side effect due to its hormonal effects on the body. Tinnitus (choice A), which is a ringing in the ears, is not typically associated with clomiphene citrate. Urinary frequency (choice B) is not a common adverse effect of this medication. Chills (choice D) are also not commonly linked to clomiphene citrate use.

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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