Nursing Elites

1. To confirm respiratory distress syndrome (RDS) in a newborn, what should the nurse assess?

• A. Assess diaphragmatic breathing.
• B. Assess heart sounds.
• C. Monitor blood oxygen levels.
• D. Check for signs of infection.

Correct answer: A

Rationale: To confirm respiratory distress syndrome (RDS) in a newborn, the nurse should assess diaphragmatic breathing. In RDS, the baby may have difficulty breathing due to immature lungs, leading to shallow, rapid breathing movements. Assessing diaphragmatic breathing directly evaluates the respiratory effort and can help identify the presence of RDS. Choice B, assessing heart sounds, is not specific to diagnosing RDS but could be relevant for other conditions. Choice C, monitoring blood oxygen levels, is important but alone may not confirm RDS. Choice D, checking for signs of infection, is not a direct indicator of RDS but rather suggests a different issue.

2. The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

• A. Positive Babinski reflex.
• B. Flexion of all four extremities.
• C. Heart rate of 220 beats/min.
• D. Cries vigorously when stimulated.

Correct answer: D

Rationale: A vigorous cry upon stimulation indicates that the newborn has good respiratory effort and is transitioning well to life outside the womb. It shows that the infant's airways are clear, and they are able to establish effective breathing, a crucial aspect of transitioning successfully to extrauterine life. Choices A, B, and C are not the best indicators of successful transition to extrauterine life. The Babinski reflex and flexion of extremities are normal neonatal reflexes and do not specifically indicate successful transition. A heart rate of 220 beats/min is abnormally high for a newborn and could indicate distress rather than a smooth transition.

3. During a well-child visit for their child, one of the parents with an autosomal dominant disorder tells the nurse, 'We don’t plan on having any more children, since the next child is likely to inherit this disorder.' How should the nurse respond?

• A. Explain that the risk of inheriting the disorder decreases by 50% with each child the couple has.
• B. Acknowledge that the next child will inherit the disorder since the first child did not.
• C. Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked.
• D. Confirm that there is a 50% chance of their future children inheriting the disorder.

Correct answer: D

Rationale: Confirming that there is a 50% chance of their future children inheriting the disorder is the correct response in this situation. Autosomal dominant disorders have a 50% chance of being passed on to each child. Providing accurate genetic counseling is essential to help the parents make informed decisions about family planning. Choices A, B, and C are incorrect. Choice A is inaccurate because the risk of inheriting an autosomal dominant disorder remains at 50% for each child regardless of the number of children the couple has. Choice B is not appropriate as it does not provide helpful information or support to the parents. Choice C is misleading because autosomal dominant disorders follow a specific inheritance pattern and are not sex-linked.

4. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?

• A. Provide an opportunity for the parents to hold their infant in privacy.
• B. Assist the couple in completing a request for autopsy.
• C. Encourage the couple to seek family counseling within the next few weeks.
• D. Explain the possible causes of fetal demise.

Correct answer: A

Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.

5. How can a nurse make a blind 8-year-old girl admitted to the hospital more comfortable?

• A. Bring familiar toys from home, such as a bear or doll.
• B. Explain the surroundings to the child.
• C. Allow the child to explore the room.
• D. Provide audio books and music.

Correct answer: A

Rationale: The correct answer is to bring familiar toys from home, such as a bear or doll. This action provides comfort and a sense of security for the child, as it allows her to have familiar objects around her in an unfamiliar environment, which can help reduce anxiety and stress during her hospital stay.

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