Nursing Elites

1. The parents of a child hospitalized with asthma who is recovering and is being prepared for discharge are receiving home care instructions from the nurse. Which statement by a parent indicates a need for further instruction?

• A. Coughing spells may be triggered by dust or smoke
• B. Vomiting may occur when our child has coughing episodes
• C. We need to encourage our child to drink fluids
• D. We need to maintain droplet precautions and a quiet environment for at least 2 weeks

Correct answer: D

Rationale: The statement 'We need to maintain droplet precautions and a quiet environment for at least 2 weeks' indicates a need for further instruction. Asthma management does not typically require maintaining droplet precautions. The focus should be on environmental control, medication adherence, and monitoring symptoms rather than droplet precautions, which are more relevant for contagious respiratory infections.

2. The nurse is preparing to administer erythromycin eye ointment to a newborn. The mother asks why this is necessary. What is the nurse's best response?

• A. It helps to prevent eye infections caused by bacteria in the birth canal.
• B. It protects the baby's eyes from bright lights in the delivery room.
• C. It prevents the development of jaundice.
• D. It helps the baby see more clearly after birth.

Correct answer: A

Rationale: Erythromycin eye ointment is administered to newborns to prevent eye infections caused by bacteria present in the birth canal. This ointment does not have a direct correlation with protecting the baby's eyes from bright lights, preventing jaundice, or improving the baby's vision clarity post-birth.

3. A postpartum client asks the nurse about resuming sexual activity. What is the nurse's best response?

• A. You can resume sexual activity as soon as you feel ready.
• B. It is best to wait until your postpartum check-up before resuming sexual activity.
• C. You should wait at least 6 weeks before resuming sexual activity.
• D. It is safe to resume sexual activity once your lochia has stopped.

Correct answer: B

Rationale: The best response for the nurse is to advise the postpartum client to wait until the postpartum check-up before resuming sexual activity. This allows for complete healing to ensure the client's well-being and provides an opportunity to address any concerns with the healthcare provider. Choice A is incorrect because resuming sexual activity should be based on medical advice rather than personal readiness. Choice C is incorrect as the 6-week recommendation is a general guideline but individual circumstances may vary. Choice D is incorrect as the cessation of lochia is not the sole indicator for safe resumption of sexual activity.

4. Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

• A. Amount and area of vernix coverage
• B. Creases on the sole
• C. Size of the areola
• D. Body surface temperature

Correct answer: A

Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.

5. Upon delivery of a baby's head, you see that the umbilical cord is wrapped around its neck. Initial treatment for this condition should include:

• A. Clamping and cutting the umbilical cord.
• B. Gently pulling on the cord to facilitate removal.
• C. Trying to remove the cord from around the neck.
• D. Keeping the cord moist and providing rapid transport.

Correct answer: C

Rationale: When encountering a situation where the umbilical cord is wrapped around a baby's neck upon delivery, the initial treatment should involve trying to remove the cord from around the neck gently. It is crucial to handle this situation delicately to avoid causing harm to the baby. Attempting to ease the cord over the baby's head without pulling or tightening can help prevent potential complications associated with cord compression. Choice A, clamping and cutting the umbilical cord, is not recommended as it can lead to abrupt deprivation of oxygen to the baby. Choice B, gently pulling on the cord, can worsen the situation by tightening the cord around the baby's neck. Choice D, keeping the cord moist and providing rapid transport, is not the immediate concern and does not address the potential risks of cord compression during delivery. Therefore, the priority is to carefully attempt to remove the cord from around the baby's neck to ensure a safe delivery.

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