Nursing Elites

1. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?

• A. Jaundice.
• B. Poor feeding.
• C. Brain injury.
• D. Hypoglycemia.

Correct answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.

2. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

• A. Use a sterile item to tie off the umbilical cord.
• B. Provide privacy for the woman.
• C. Reassure the husband and try to keep him calm.
• D. Put the newborn to breast.

Correct answer: D

Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.

3. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

• A. Body temperature.
• B. Level of pain.
• C. Time of first void.
• D. Number of vessels in the cord.

Correct answer: D

Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.

4. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

• A. Which symptom did you experience first?
• B. Are you consuming large amounts of salty foods?
• C. Have you traveled to a foreign country recently?
• D. Do you have a history of rheumatic fever?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

5. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?

• A. Notify the healthcare provider or anesthesiologist immediately.
• B. Continue to assess the blood pressure every 5 minutes.
• C. Place the woman in a lateral position.
• D. Turn off the continuous epidural.

Correct answer: C

Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia. Turning off the continuous epidural would not be the initial action as it may not be necessary and could lead to inadequate pain relief for the client. Notifying the healthcare provider or anesthesiologist immediately is premature and should be done after attempting non-invasive interventions. Continuing to assess the blood pressure every 5 minutes is important, but placing the woman in a lateral position should be the first intervention to address the hypotension.

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