Nursing Elites

1. A postpartum client is experiencing difficulty voiding. What should the nurse include in the care plan to assist the client?

• A. Encourage the client to drink caffeine-free beverages.
• B. Apply a warm compress to the client's lower abdomen.
• C. Encourage increased fluid intake to promote urinary flow.
• D. Assist the client with Kegel exercises.

Correct answer: B

Rationale: Applying a warm compress to the lower abdomen can help relax the muscles and stimulate voiding in postpartum clients. It promotes vasodilation, increases blood flow to the area, and can aid in relieving urinary retention. Encouraging caffeine-free beverages can also be beneficial as caffeine can irritate the bladder and worsen the situation. Increasing fluid intake helps prevent urinary stasis and promotes bladder emptying. Kegel exercises can strengthen pelvic floor muscles over time, but in the immediate situation of difficulty voiding, a warm compress is more appropriate.

2. What is the MOST effective way to prevent cardiopulmonary arrest in a newborn?

• A. Ensure effective oxygenation and ventilation.
• B. Administer blow-by oxygen as soon as the newborn is born.
• C. Perform an Apgar assessment every 5 minutes.
• D. Suction the newborn's mouth and nose every 3 minutes.

Correct answer: A

Rationale: The most effective way to prevent cardiopulmonary arrest in a newborn is to ensure effective oxygenation and ventilation. This is crucial in maintaining adequate oxygen supply and preventing respiratory distress or failure, which are significant factors leading to cardiopulmonary arrest. Providing appropriate ventilation support and oxygenation can help sustain the newborn's vital functions and reduce the risk of cardiopulmonary compromise.

3. During the initial assessment of the newborn, which of the following data would be considered normal?

• A. Chest circumference 31.5 cm, head circumference 33.5 cm
• B. Chest circumference 30 cm, head circumference 29 cm
• C. Chest circumference 38 cm, head circumference 31.5 cm
• D. Chest circumference 32.5 cm, head circumference 36 cm

Correct answer: A

Rationale: The correct answer is A. During the initial assessment of a newborn, the average head circumference at birth is 32 to 37 cm, while the average chest circumference ranges from 30 to 35 cm. Normally, the head's circumference is about 2 cm greater than the chest circumference at birth. Choice A provides measurements of chest circumference 31.5 cm and head circumference 33.5 cm, both falling within the normal range in terms of actual size and relative size. Choices B, C, and D do not align with the typical measurements seen in a healthy newborn. Choice B has both circumferences below the average range, choice C has the chest circumference above the average, and choice D has the head circumference notably higher than the chest circumference, which is not typical for a newborn.

4. When managing Akosua Adepa, an eight-year-old diagnosed with Asthma, the nurse will consider the following as complications EXCEPT:

• A. Cor pulmonale
• B. Respiratory arrest
• C. Respiratory distress
• D. Respiratory failure

Correct answer: C

Rationale: When managing a pediatric patient with asthma, the nurse needs to be vigilant about potential complications. While cor pulmonale, respiratory arrest, and respiratory failure are known complications of asthma, respiratory distress is not typically considered a direct complication. Respiratory distress is more of a symptom or a sign of worsening asthma, indicating the need for immediate intervention to prevent progression to more severe complications.

5. When is it MOST appropriate to clamp and cut the umbilical cord?

• A. Before the newborn has taken its first breath
• B. After the placenta has completely delivered
• C. As soon as the cord has stopped pulsating
• D. Immediately following delivery of the newborn

Correct answer: C

Rationale: The ideal time to clamp and cut the umbilical cord is when it has stopped pulsating. This allows for the transfer of remaining blood from the placenta to the newborn, which can be beneficial for the baby's health and iron stores. Clamping the cord too early can deprive the newborn of this essential blood volume. Waiting for the pulsations to cease ensures that the baby receives the maximum benefits from delayed cord clamping.

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