Nursing Elites

1. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?

• A. Inform and assure the mother that this is normal weight loss.
• B. Encourage the mother to increase the frequency of breastfeeding.
• C. After verifying the accuracy of weight, notify the healthcare provider.
• D. Monitor the stool and urine output of the neonate for the last 24 hours.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.

2. Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?

• A. Swaddle the infant in a warm blanket.
• B. Obtain a heel stick blood glucose level.
• C. Place a pulse oximeter on the heel.
• D. Document the findings in the record.

Correct answer: B

Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.

3. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?

• A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
• B. Pyloric obstruction causes reflux and projectile hematemesis.
• C. Partial imperforated anal opening limits passage of stools.
• D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.

Correct answer: A

Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.

4. A postpartum client who is Rh-negative refuses to receive RhoGAM after the delivery of an infant who is Rh-positive. Which information should the nurse provide this client?

• A. RhoGAM prevents maternal antibody formation for future Rh-positive babies.
• B. RhoGAM is not necessary unless all of her pregnancies are Rh-positive.
• C. The Rh-positive factor from the fetus threatens her blood cells.
• D. The mother should receive RhoGAM when the baby is Rh-negative.

Correct answer: A

Rationale: The correct answer is A. RhoGAM is administered to Rh-negative individuals after exposure to Rh-positive blood to prevent the development of antibodies that could harm future Rh-positive babies during subsequent pregnancies. By refusing RhoGAM after the delivery of an Rh-positive infant, the mother risks developing these antibodies, which could lead to hemolytic disease in future pregnancies with Rh-positive babies. Therefore, it is crucial for the nurse to explain to the client that receiving RhoGAM prevents the formation of maternal antibodies against Rh-positive blood, safeguarding the health of future babies. Choices B, C, and D are incorrect. Choice B is incorrect because RhoGAM is necessary after exposure to Rh-positive blood, regardless of the Rh status of future pregnancies. Choice C is incorrect as it does not accurately convey the purpose of RhoGAM administration. Choice D is incorrect because RhoGAM is specifically given after exposure to Rh-positive blood, not when the baby is Rh-negative.

5. A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?

• A. Assess her blood pressure.
• B. Apply an ice pack to the perineum.
• C. Allow the infant to breastfeed.
• D. Massage the fundus vigorously.

Correct answer: A

Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding. Applying an ice pack to the perineum (choice B) would not address the ongoing bleeding issue. Allowing the infant to breastfeed (choice C) may not be safe if there is significant bleeding. Massaging the fundus vigorously (choice D) is contraindicated when there is continuous bleeding as it can worsen the bleeding or cause further harm.

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