Nursing Elites

1. When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?

• A. Babinski
• B. Rooting
• C. Moro
• D. Stepping

Correct answer: B

Rationale: The correct answer is B: Rooting. The rooting reflex is crucial in newborns as it helps them locate the nipple for feeding. This reflex involves turning the head towards a stimulus that touches the cheek or mouth, aiding in the process of latching onto the breast for breastfeeding. The Babinski reflex is the fanning out and curling of the toes when the sole of the foot is stroked, the Moro reflex is the startle reflex in response to a sudden noise or movement, and the stepping reflex is the appearance of taking steps when an infant is held upright with feet touching a solid surface. Therefore, choices A, C, and D are incorrect as they do not play a direct role in promoting a newborn to latch during breastfeeding.

2. A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?

• A. Perform effleurage during contractions.
• B. Place the client in lithotomy position.
• C. Assist the client to the hands and knees position.
• D. Apply a scalp electrode to the fetus.

Correct answer: C

Rationale: The nurse should assist the client into the hands and knees position during contractions to help relieve her back pain and facilitate the rotation of the fetus from the posterior to an anterior occiput position. This position can aid in optimal fetal positioning for delivery. Choice A, performing effleurage, is a massage technique that may provide comfort but does not address the fetal position. Placing the client in lithotomy position (Choice B) may not be ideal for a client experiencing back pain due to the occiput posterior position. Applying a scalp electrode to the fetus (Choice D) is not indicated solely for addressing the client's back pain.

3. A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

• A. I will inform the provider that you are having these feelings.
• B. It is normal to have these feelings during the first few months of pregnancy.
• C. You should be happy that you are going to bring new life into the world.
• D. I am going to make an appointment with the counselor for you to discuss these thoughts.

Correct answer: B

Rationale: During the first few months of pregnancy, it is common for individuals to experience mixed feelings due to hormonal changes and the significant life adjustments that come with pregnancy. The nurse's response should acknowledge the client's feelings as normal and provide reassurance rather than dismissive or directive statements. By acknowledging the normalcy of these emotions, the nurse validates the client's experience and offers support during this critical time. Choices A, C, and D are less appropriate. Choice A focuses on informing the provider without addressing the client's emotions directly. Choice C disregards the client's current feelings and imposes a specific emotional response. Choice D jumps to scheduling a counseling appointment without first acknowledging the client's emotions or providing immediate support and validation.

4. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

• A. Prepare for a cesarean birth.
• B. Assist the client to an upright position.
• C. Prepare for an immediate vaginal delivery.
• D. Assist the client to turn onto her side.

Correct answer: D

Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.

5. A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

• A. Allow the sibling to hold the newborn during a bath.
• B. Make sure the sibling kisses the newborn each night.
• C. Obtain a gift from the newborn to present to the sibling.
• D. Switch the sibling's room with the nursery.

Correct answer: C

Rationale: To help a 7-year-old child accept a new family member, it is important to involve them in the process. Obtaining a gift from the newborn to present to the sibling is a thoughtful gesture that can make the older child feel included and valued in the family dynamic. This strategy fosters a sense of connection and understanding between the siblings, promoting acceptance and bonding. Choices A, B, and D are incorrect as they do not directly involve the older sibling in a positive and inclusive manner. Allowing the sibling to hold the newborn during a bath or making them kiss the newborn might not resonate well with the 7-year-old and could potentially create negative feelings. Switching the sibling's room with the nursery is a major change that may not necessarily promote acceptance and bonding, and it could lead to feelings of displacement or confusion.

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