Nursing Elites

1. 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.

2. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the client's nursing care plan?

• A. Assess temperature every hour.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations every 4 hours.
• D. Keep an airway at the bedside.

Correct answer: D

Rationale: In the case of eclampsia, the priority intervention is to keep an airway at the bedside. Eclampsia is associated with a high risk of convulsions, and having an airway readily available is crucial for prompt intervention in the event of seizures. Assessing temperature, allowing family visitation, and monitoring vital signs are important aspects of care but ensuring airway patency takes precedence in this situation to manage potential complications and ensure the client's safety.

3. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?

• A. Auscultate the lungs for respiratory pneumonia.
• B. Change to latex-free gloves when handling infant.
• C. Draw blood to analyze for streptococcal infection.
• D. Apply zinc oxide to perineum with each diaper change.

Correct answer: B

Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.

4. What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.

5. Just after delivery, a new mother tells the nurse, 'I was unsuccessful breastfeeding my first child, but I would like to try with this baby.' Which intervention is best for the LPN/LVN to implement first?

• A. Assess the husband's feelings about his wife's decision to breastfeed their baby.
• B. Ask the client to describe why she was unsuccessful with breastfeeding her last child.
• C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
• D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Correct answer: D

Rationale: The correct intervention is to provide immediate assistance to the mother to begin breastfeeding as soon as possible after delivery. This approach helps initiate bonding and successful breastfeeding. Taking action promptly can address the mother's desire to breastfeed and promote positive outcomes for both the mother and the newborn.

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