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What organization developed the CJMM?
- A. ACOG
- B. ANA
- C. AWHONN
- D. NCSBN
Correct Answer: D
Rationale: The National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (CJMM).
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What steps are included in the QSEN steps for rewarming a neonate at risk for cold stress? Select all that apply.
- A. placing the neonate under the radiant warmer
- B. putting a pulse oximeter on the neonate
- C. assessing a blood glucose level
- D. calling the NICU team for assessment
Correct Answer: A
Rationale: Steps include placing the neonate under a radiant warmer and assessing blood glucose levels.
The nurse has access to the results of a karyotype sent out for their patient via an electronic medical record. The parents have accessed the results on their MyChart phone application and have asked the nurse what the results 45, X mean. What is the best response from the nurse?
- A. The results indicate your child may have Turner syndrome.
- B. Your results are 45, X; you will have to wait to talk with the geneticist.
- C. Your results indicate that your daughter has a serious lifelong disease.
- D. I’m not sure; I’ll call the provider.
Correct Answer: A
Rationale: Karyotype 45, X indicates Turner syndrome, a condition affecting females.
The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?
- A. Place a small object in the infant's hand.
- B. Stroke the side of the infant's cheek.
- C. Touch the tip of the infant's tongue.
- D. Turn the infant's head to one side.
Correct Answer: C
Rationale: The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
- A. tell the patient to wear a bra at all times to provide more support to breast tissue.
- B. have the patient put the infant to her breast more frequently.
- C. place ice packs on breast tissue after infant feeding.
- D. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
Correct Answer: B
Rationale: Step 1: Breast tenderness and fullness between feedings indicate engorgement, a common issue in breastfeeding mothers.
Step 2: Putting the infant to the breast more frequently helps empty the breast and prevents engorgement.
Step 3: Regular feeding stimulates milk production and prevents discomfort.
Step 4: This approach is effective in addressing the underlying issue of engorgement.
Summary:
A: Wearing a bra at all times may not address the root cause of engorgement.
C: Ice packs can provide temporary relief but do not prevent engorgement.
D: Normalizing the issue without providing a solution does not address the discomfort.
The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information doesn't the nurse present to the mother?
- A. The blood test does not indicate a pathological disease.
- B. The newborn's liver converts bilirubin to a water-soluble substance.
- C. An abundance of RBCs and RBC short life span contributes to the condition.
- D. The newborn's condition is also referred to as hyperbilirubinemia.
Correct Answer: D
Rationale: The correct answer is D because the nurse does not mention the term "hyperbilirubinemia" to the mother. Instead, the nurse focuses on explaining the high level of unconjugated bilirubin causing jaundice.
A: The nurse likely mentioned that the blood test does not indicate a pathological disease to reassure the mother that jaundice is a common condition in newborns.
B: The nurse would have explained that the newborn's liver converts bilirubin to a water-soluble substance as part of the discussion on how bilirubin is processed in the body.
C: An abundance of RBCs and their short lifespan contributing to jaundice would be relevant information that the nurse would provide to explain the underlying causes of the condition.