Nursing Elites

1. The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?

• A. Lanugo mostly gone, little vernix remaining on the body
• B. Prominent clitoris, enlarging labia minora, patent anus
• C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
• D. Skin opaque, cracking at wrists and ankles, no visible vessels

Correct answer: B

Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.

2. What is the appropriate treatment for a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color?

• A. Oxygen, back slaps, and transport.
• B. Subdiaphragmatic thrusts until the object is expelled.
• C. Assisted ventilations, back slaps, and transport.
• D. Supplemental oxygen and transport.

Correct answer: D

Rationale: For a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color, the appropriate treatment includes providing supplemental oxygen and arranging for transport to a healthcare facility. Oxygen helps alleviate the respiratory distress, and transport ensures the child receives further evaluation and care by healthcare professionals. Back slaps and subdiaphragmatic thrusts are not recommended for a child with a mild airway obstruction and normal skin color, as these interventions are typically reserved for more severe cases of airway obstruction.

3. A postpartum client is experiencing difficulty voiding. What should the nurse include in the care plan to assist the client?

• A. Encourage the client to drink caffeine-free beverages.
• B. Apply a warm compress to the client's lower abdomen.
• C. Encourage increased fluid intake to promote urinary flow.
• D. Assist the client with Kegel exercises.

Correct answer: B

Rationale: Applying a warm compress to the lower abdomen can help relax the muscles and stimulate voiding in postpartum clients. It promotes vasodilation, increases blood flow to the area, and can aid in relieving urinary retention. Encouraging caffeine-free beverages can also be beneficial as caffeine can irritate the bladder and worsen the situation. Increasing fluid intake helps prevent urinary stasis and promotes bladder emptying. Kegel exercises can strengthen pelvic floor muscles over time, but in the immediate situation of difficulty voiding, a warm compress is more appropriate.

4. What is the reason for Asthma in 4-year-old Mabele, as Mrs. Joyce Thomson inquires? How would you explain it?

• A. Asthma occurs due to inflammation of the respiratory tract triggered by infections.
• B. An asthmatic attack can occur when the child is exposed to certain allergens, triggering an allergic reaction in the bronchioles that causes bronchial constriction.
• C. An asthmatic attack is a response to the release of inflammatory mediators to epithelial cells, affecting the autonomic neural control of the airway.
• D. Asthma is not an inborn problem; it involves abnormal growth of the bronchial tree causing restriction.

Correct answer: B

Rationale: Asthma in children like Mabele can be triggered by exposure to allergens, leading to an allergic reaction in the bronchioles. This reaction causes constriction of the bronchial tree, resulting in an asthmatic attack. It is essential for caregivers to identify and minimize exposure to these triggers to manage and prevent asthma episodes effectively.

5. What advice should a school-age child with type 1 diabetes mellitus follow to prevent hypoglycemia during soccer practice?

• A. Drink a cup of orange juice before soccer practice
• B. Eat twice the amount normally eaten at lunchtime
• C. Take half the amount of prescribed insulin on practice days
• D. Take the prescribed insulin at noontime rather than in the morning

Correct answer: A

Rationale: Drinking orange juice before soccer practice is recommended to prevent hypoglycemia in children with type 1 diabetes. Orange juice contains fast-acting carbohydrates that can quickly raise blood sugar levels if they drop during physical activity. Eating twice the amount normally eaten at lunchtime can lead to hyperglycemia, which is high blood sugar, rather than preventing hypoglycemia. Adjusting insulin doses should only be done under the guidance of a healthcare provider. Taking insulin at noontime rather than in the morning does not directly address preventing hypoglycemia during afternoon soccer practice.

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