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. 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.

3. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?

• A. Initiate an intravenous infusion.
• B. Observe the FHR pattern for 30 more minutes.
• C. Schedule a biophysical profile.
• D. Place an acoustic stimulator on the abdomen.

Correct answer: D

Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.

4. A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

• A. Inspect the client's face for edema.
• B. Ascertain the frequency of headaches.
• C. Evaluate for a history of cluster headaches.
• D. Observe and time the client's contractions.

Correct answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

5. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

• A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
• B. Remove restraints one at a time to provide range of motion exercises.
• C. Record observation of the restraints q2h and ensure that they are in place at all times.
• D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

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