Nursing Elites

1. The healthcare provider is providing postpartum care to a client who had a vaginal delivery. Which finding would require further assessment?

• A. Perineal swelling
• B. Moderate lochia serosa
• C. Headache unrelieved by analgesics
• D. Breast engorgement

Correct answer: C

Rationale: A headache unrelieved by analgesics can be a sign of a serious condition such as preeclampsia, which is a life-threatening condition characterized by high blood pressure and often protein in the urine. Prompt assessment and intervention are crucial to prevent complications for both the mother and baby.

2. Which of the following statements regarding 2-rescuer child CPR is correct?

• A. The chest should be compressed with one hand, and a compression-to-ventilation ratio of 30:2 should be used.
• B. The chest should not be allowed to fully recoil in between compressions.
• C. A compression-to-ventilation ratio of 15:2 should be used if an advanced airway is in place.
• D. Compress the chest with one or two hands to a depth equal to one-third the diameter of the chest.

Correct answer: D

Rationale: During 2-rescuer child CPR, it is important to compress the chest with one or two hands to a depth equal to one-third the diameter of the chest. This technique ensures effective chest compressions are being delivered to help circulate blood and oxygenate the child's body. Choice A is incorrect because both hands should be used for chest compressions in 2-rescuer CPR. Choice B is incorrect as allowing the chest to fully recoil between compressions is essential to create negative pressure and facilitate blood flow back to the heart. Choice C is incorrect as the standard compression-to-ventilation ratio for child CPR is 30:2, regardless of whether an advanced airway is in place.

3. One of the signs of CHF is shortness of breath. What is the term for shortness of breath when lying down?

• A. Platypnea
• B. Orthopnea
• C. Apnea
• D. Epistaxis

Correct answer: B

Rationale: Orthopnea is the specific term used to describe shortness of breath when lying down. This condition is commonly seen in patients with congestive heart failure (CHF) due to the redistribution of fluid in the body when changing positions. Platypnea refers to shortness of breath that worsens when sitting or standing, apnea is the cessation of breathing, and epistaxis is the medical term for a nosebleed. Therefore, the correct answer is B (Orthopnea).

4. After an advanced airway device has been inserted in a 6-month-old infant in cardiopulmonary arrest, you should deliver ventilations at a rate of:

• A. 10 to 12 breaths/min.
• B. 12 to 20 breaths/min.
• C. 6 to 8 breaths/min.
• D. 8 to 10 breaths/min.

Correct answer: D

Rationale: The appropriate ventilation rate for an infant with an advanced airway is 8 to 10 breaths per minute.

5. Following the initial steps of resuscitation, a newborn remains apneic and cyanotic. What should you do next?

• A. begin ventilations with a bag-mask device.
• B. gently flick the soles of their feet for up to 60 seconds.
• C. immediately suction their mouth and nose.
• D. start CPR if the heart rate is less than 80 beats/min.

Correct answer: A

Rationale: If a newborn remains apneic and cyanotic after the initial resuscitation steps, the next appropriate action is to begin ventilations with a bag-mask device. This helps provide oxygen to the newborn and can be crucial in supporting their respiratory efforts. Option B of flicking the soles of their feet is not recommended in this scenario as the priority is addressing the respiratory distress. Option C of suctioning their mouth and nose is not the immediate next step if the newborn is not spontaneously breathing. Option D of starting CPR based only on the heart rate is not the first-line intervention for an apneic and cyanotic newborn.

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