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 client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

• A. Betamethasone (Celestone).
• B. Magnesium sulfate.
• C. Terbutaline (Brethine).
• D. Ampicillin.

Correct answer: A

Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.

3. What action should be implemented when preparing to measure the fundal height of a pregnant client?

• A. Have the client empty her bladder.
• B. Request the client lie on her left side.
• C. Perform Leopold's maneuvers first.
• D. Give the client some cold juice to drink.

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

4. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

5. The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

• A. Elicit a positive scarf sign on the affected side.
• B. Observe for an asymmetrical Moro (startle) reflex.
• C. Watch for swelling of fingers on the affected side.
• D. Note paralysis of the affected extremity and muscles.

Correct answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

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