Nursing Elites

1. What assessment finding places a newborn at risk for developing physiologic jaundice?

• A. Cephalohematoma
• B. Mongolian spots
• C. Telangiectatic nevi
• D. Molding

Correct answer: A

Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.

2. The healthcare provider is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

• A. (+) Moro reflex
• B. Heart rate is 80 bpm
• C. Respirations are irregular
• D. Uneven head shape

Correct answer: B

Rationale: A heart rate of 80 bpm is least likely to be observed in a normal newborn. The normal heart rate range for a newborn is usually higher than 80 bpm, typically ranging from 120-160 bpm. The Moro reflex (choice A) is a normal newborn reflex, respirations being irregular (choice C) are expected due to the immature respiratory control center, and an uneven head shape (choice D) is common due to molding during vaginal delivery.

3. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

• A. Weighing the diapers
• B. Inserting a Foley catheter
• C. Comparing intake with output
• D. Measuring the amount of water added to formula

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

4. What is the most important intervention to decrease the stressors of hospitalization for a 9-month-old infant being treated for a bacterial infection?

• A. Encourage the infant's parents to remain at the bedside and actively participate in the infant's care.
• B. Provide a brightly lit environment for the infant.
• C. Play tapes of the mother's voice.
• D. Assign the same nurse to the infant as much as possible.

Correct answer: A

Rationale: Encouraging the infant's parents to remain at the bedside and actively participate in the infant's care is crucial in decreasing the stressors of hospitalization for the infant. Parental presence provides comfort and security, promotes bonding, and maintains a sense of familiarity for the infant during a potentially stressful situation. This involvement can help reduce anxiety and promote better outcomes for the infant's emotional well-being and overall hospital experience. Providing a brightly lit environment (choice B) can actually increase stress for the infant, as infants generally prefer dimly lit environments for better sleep. Playing tapes of the mother's voice (choice C) may offer some comfort but does not substitute for parental presence. While assigning the same nurse to the infant (choice D) can provide continuity of care, it is not as effective as having the parents present for emotional support and bonding.

5. What action should you take if a newborn's heart rate is 50 beats/min?

• A. Begin chest compressions.
• B. Reassess in 30 seconds.
• C. Administer blow-by oxygen.
• D. Start positive-pressure ventilations.

Correct answer: D

Rationale: If a newborn's heart rate is below 60 beats per minute, the appropriate action is to start positive-pressure ventilations. Ventilations help deliver oxygen to the newborn's body and support respiratory function, which is critical in cases of bradycardia. Chest compressions are not recommended until the heart rate is below 60 despite adequate ventilation. Reassessment is essential but not the immediate action required in this scenario. Administering blow-by oxygen alone may not effectively address the underlying cause of bradycardia, making positive-pressure ventilations the priority intervention in this case.

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