Nursing Elites

1. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

• A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
• B. A gravida I para 1 that is Rh negative with an Rh-positive baby
• C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
• D. A gravida IV para 2 that is Rh negative with an Rh-negative baby

Correct answer: D

Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.

2. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

3. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?

• A. prosecuting the perpetrator
• B. managing symptoms of anxiety and fear
• C. determining if the memories are real
• D. collaborating with the client's story

Correct answer: B

Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.

4. When questioning an elder about suspected abuse, how should the nurse keep the questions?

• A. Nonjudgmental.
• B. Probing.
• C. Confrontational.
• D. Indirect.

Correct answer: A

Rationale: When questioning an elder about suspected abuse, the nurse should keep the questions nonjudgmental. This approach helps the elder feel safe and more willing to share information. Probing questions might be perceived as invasive, confrontational questions can lead to defensiveness and denial, and indirect questions may not elicit the necessary information, resulting in confusion or misinterpretation.

5. If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?

• A. Document the finding
• B. Send a specimen to the lab
• C. Strain the dialysate
• D. Obtain a complete blood count

Correct answer: B

Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.

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