Nursing Elites

1. 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.

2. During an examination for possible cryptorchidism in an infant, what technique should be used?

• A. Place the infant in a warm room and use a calm approach.
• B. Hold the scrotum and palpate gently.
• C. Cleanse the penis with an antiseptic-soaked pad.
• D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

3. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

• A. Slowly increasing urinary output over the last week.
• B. Respiratory rate changes from the 40s to the 60s.
• C. Changes in apical heart rate from the 180s to the 140s.
• D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

Correct answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.

4. A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?

• A. Massage the calf and foot.
• B. Extend the leg and dorsiflex the foot.
• C. Lower the leg off the side of the bed.
• D. Elevate the leg above the heart.

Correct answer: B

Rationale: During active labor, if a client complains of leg cramps, extending the leg and dorsiflexing the foot can help relieve the muscle cramps by stretching the affected muscles. This intervention promotes circulation and can alleviate discomfort associated with leg cramps.

5. Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?

• A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
• B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
• C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
• D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Correct answer: D

Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.

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