Nursing Elites

1. 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.

2. 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.

3. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:

• A. Increases peripheral vascular resistance
• B. Decreases arterial blood flow away from the heart
• C. It's a common resting position when a child is tachycardic
• D. Increases the workload of the heart

Correct answer: A

Rationale: Squatting increases systemic vascular resistance, which leads to a reduction in the right-to-left shunting of blood in children with tetralogy of Fallot. This helps improve oxygenation by balancing the pulmonary and systemic blood flow. The squatting position decreases the pressure in the right ventricle and reduces the magnitude of the right-to-left shunt by increasing afterload, thereby improving oxygenation. Choices B, C, and D are incorrect because squatting does not decrease arterial blood flow away from the heart, is not related to being tachycardic, and does not increase the workload of the heart.

4. Which of the following signs or symptoms is more common in children than adults following an isolated head injury?

• A. Changes in pupillary reaction
• B. Tachycardia and diaphoresis
• C. Nausea and vomiting
• D. Altered mental status

Correct answer: C

Rationale: Nausea and vomiting are more common in children than adults following an isolated head injury. Children often present with gastrointestinal symptoms like nausea and vomiting after a head injury due to differences in physiological responses compared to adults.

5. Which of the following injuries is MOST indicative of child abuse?

• A. Multiple bruises to the shins
• B. Burned hand with splash marks
• C. Small laceration to the chin
• D. Bruising to the upper back

Correct answer: D

Rationale: Bruising to the upper back is more suspicious for child abuse compared to the other listed injuries. In young children, injuries like bruises to the upper back are less likely to be accidental and may raise concerns about physical abuse. The upper back is an area less prone to accidental injuries during play or falls. Multiple bruises to the shins are common in active children. A burned hand with splash marks may suggest accidental burns. A small laceration to the chin is also a common injury from falls in children. Therefore, the bruising on the upper back is more concerning for possible child abuse.

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