Nursing Elites

1. Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?

• A. Request parental consent to administer the vaccine.
• B. Check the infant for jaundice.
• C. Check the infant's temperature.
• D. Obtain parental consent to administer the vaccine.

Correct answer: D

Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.

2. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

3. A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent?

• A. Using a latex condom is a good method for reducing the risk of sexually transmitted infections (STIs).
• B. The only way to reduce the risk of transmission of STIs is abstinence.
• C. A spermicide needs to be used along with a condom to prevent transmission of STIs.
• D. Using a latex condom can reduce the risk of transmission of STIs.

Correct answer: D

Rationale: The correct answer is that using a condom during intercourse can reduce the risk of STI transmission. Abstinence is a way to prevent STIs, but not the only way. Using a spermicide along with a condom can help prevent pregnancy, not STIs. While condoms may fail to prevent pregnancy, they are effective in reducing the risk of STI transmission. Therefore, using a latex condom for pregnancy prevention is not directly related to preventing the transmission of STIs.

4. All of the following factors, when identified in the history of a family, are correlated with poverty except:

• A. high infant mortality rate
• B. frequent use of Emergency Departments
• C. consultation with folk healers
• D. low incidence of dental problems

Correct answer: D

Rationale: Factors correlated with poverty often include a high infant mortality rate, frequent use of Emergency Departments, and consultation with folk healers, as these indicate limited access to healthcare. Dental problems are prevalent in poverty due to a lack of preventive care and access to treatments. High infant mortality is a significant issue linked with poverty as it reflects poor healthcare access. Families in poverty might resort to Emergency Departments for healthcare due to financial barriers. Consulting folk healers is common in communities with limited access to formal healthcare. However, a low incidence of dental problems is less likely in impoverished families due to the lack of preventive services and the presence of other health issues.

5. A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?

• A. Stethoscope
• B. Doppler transducer
• C. Fetoscope
• D. Pulse oximetry on the client and a fetoscope

Correct answer: B

Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.

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