Nursing Elites

1. The nurse is planning care for a 4-year-old girl diagnosed with a developmental disability. What should be the primary focus of treatment for this child?

• A. Teach her social skills.
• B. Assist in preventing further disability.
• C. Ensure her participation in group activities.
• D. Help her achieve her maximum potential.

Correct answer: D

Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be helping them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities. Teaching social skills (choice A) is important but is just one aspect of the comprehensive care needed. Preventing further disability (choice B) may not always be entirely achievable, but maximizing potential is a more realistic goal. Ensuring participation in group activities (choice C) is valuable for social development, but the primary focus should be on overall potential and well-being.

2. The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

• A. Positive Babinski reflex.
• B. Flexion of all four extremities.
• C. Heart rate of 220 beats/min.
• D. Cries vigorously when stimulated.

Correct answer: D

Rationale: A vigorous cry upon stimulation indicates that the newborn has good respiratory effort and is transitioning well to life outside the womb. It shows that the infant's airways are clear, and they are able to establish effective breathing, a crucial aspect of transitioning successfully to extrauterine life. Choices A, B, and C are not the best indicators of successful transition to extrauterine life. The Babinski reflex and flexion of extremities are normal neonatal reflexes and do not specifically indicate successful transition. A heart rate of 220 beats/min is abnormally high for a newborn and could indicate distress rather than a smooth transition.

3. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?

• A. Which symptom did you experience first?
• B. Are you consuming large amounts of salty foods?
• C. Have you traveled to a foreign country recently?
• D. Do you have a history of rheumatic fever?

Correct answer: D

Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.

4. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

5. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition?

• A. Gestational diabetes.
• B. Elevated blood pressure.
• C. Urinary tract infection.
• D. Swelling in lower extremities.

Correct answer: A

Rationale: The correct answer is A: Gestational diabetes. Terbutaline (Brethine) is known to cause hyperglycemia, so it is crucial to assess for gestational diabetes before administering it. Assessing for elevated blood pressure (choice B), urinary tract infection (choice C), or swelling in lower extremities (choice D) is not directly related to the potential side effect of terbutaline in causing hyperglycemia.

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