Nursing Elites

1. A newborn's parents tell the nurse that their baby is already trying to walk. How should the nurse respond?

• A. Encourage the parents to report this to the healthcare provider.
• B. Acknowledge the parents' observation.
• C. Schedule the newborn for further neurological testing.
• D. Explain the newborn’s normal stepping reflex.

Correct answer: D

Rationale: When parents report that their newborn is trying to walk, the nurse should understand that newborns exhibit a stepping reflex, which is a normal developmental response. Explaining this reflex to the parents helps them understand that it is a typical behavior seen in newborns rather than true attempts to walk. Encouraging the parents to report this to the healthcare provider (Choice A) may cause unnecessary concern since the stepping reflex is a normal part of newborn development. Acknowledging the parents' observation (Choice B) is a good communication strategy but providing education on the normal reflex is essential. Scheduling the newborn for further neurological testing (Choice C) is not indicated in this scenario as the stepping reflex is a typical finding in newborns.

2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

3. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

• A. Wear support stockings.
• B. Reduce salt in her diet.
• C. Move about every hour.
• D. Avoid constrictive clothing.

Correct answer: C

Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.

4. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as

• A. a cephalhematoma, caused by birth trauma and may last up to 8 weeks.
• B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications.
• C. molding, caused by pressure during labor and will disappear within 2 to 3 days.
• D. a subdural hematoma, which can result in lifelong damage.

Correct answer: A

Rationale: Cephalhematoma is the accumulation of blood between the periosteum and skull, often due to birth trauma, and typically resolves within weeks. It is a common finding in newborns and is not usually a cause for concern as it gradually resolves without specific treatment. Subarachnoid hematoma and subdural hematoma are different conditions that present with distinct characteristics and require different management strategies. Therefore, the correct answer is A. Subarachnoid hematoma is typically found in the subarachnoid space and requires immediate intervention, not just observation like cephalhematoma. Molding refers to the shaping of the fetal head during passage through the birth canal and is a temporary change, not a collection of blood like in cephalhematoma. Subdural hematoma is located beneath the dura mater and is associated with significant complications, unlike the self-limiting nature of cephalhematoma.

5. A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record?

• A. 3-1-2-0-3.
• B. 4-1-2-0-3.
• C. 2-1-2-1-2.
• D. 3-1-1-0-3.

Correct answer: D

Rationale: The correct GTPAL for this client is 3-1-1-0-3. G (Gravida) is 3, indicating a total of 3 pregnancies. T (Term) is 1, representing 1 full-term delivery. P (Preterm) is 1, not 2 as mentioned in the question, as twins count as one pregnancy event. A (Abortions) is 0, and L (Living) is 3, indicating 3 living children (twins count as 1). Therefore, the correct answer is 3-1-1-0-3.

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